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Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 Fax: 574-235-9578 Email: SBSJCHPC®co.st josephin.us <br />Website: http://www.sgosephcountyindiana.com/sjchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONRINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received OU 77&ty,W0 9 Application Number o2 � - �J`z-�o /9 <br />Past Reviews: ERIfS (Date of Last Review) [] NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark Local Historic District (Name) <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied Tabled Sent To Committee . Q Approved and Issued <br />DATE <br />Address of Property for proposed work: I o e, <br />1ree,11mber and Street Name <br />Name of Property Owner(s): (Please Print) rC (`J— <br />Address of Property Owner(s): d� _ ��{' f(m <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City:- <br />Phone: t - 6 c� O <br />Current Use of Building: MU` A�l ��M1 ILA <br />(Single Family — ami1y — Commercial — Government — Industrial —Vacant —etc.) <br />Type of Building Construction: UX f i�itY1C' <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: F] In-kind N Landscape New [:] Replacement (not in-kind) Demolition <br />(more than one box may be checked) j_ t <br />Description of Proposed Work: ��� �Y?SS Ih '�hr° � ar' i <br />Pr -1 V " �-e rcZJ TCl C] A <br />(� <br />hc�en , 5��e rt -1 �-e hick �5�►.t� l (! 'r <br />aZ <br />- - <br />Owner/Contractor: Fax: 5 9 ' � ' 259 5 e-mail ")t" ryA_ho )) et U \ C O" <br />lisewill correspond wi only one designee) Ca`k-t-i�'-jt ) I <br />eta and/orS I ����- C) C) G <br />t 7 <br />— APPLICATION REQWREMENTS ARE LISTED ON REVERSE SIDE — <br />