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Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax: 574235-9578 • Email: SBSJCHPC@co.st josephin.us <br />Website: http://www.sgosephcountyindiana.com/Ichp/index,html <br />OFFICE USE O »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX >1 > FFICE USE ONLY <br />Date Received Application Number �9 - 050* <br />Past Reviews: [R'4ES (Date o/LestReview) ,Q _jeK,,ct& C2&07 [� NO <br />Staff Approval authorized by: 'Title: <br />Historic Commission Review Date: /,P aZUD� <br />[� Local Landmark [5 Local Historic District (Name) {{ �� <br />National Landmark []National Register District (Name) A64 <br />Certificate of Appropriateness: <br />Denied f__j Tabled [] Sent To Committee F] Approved and Issued <br />DATE <br />Address of Property for proposed work: 414-7 as i ()c Dp . <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) ANN it A 2 tC- '9 LA KEY <br />Address of Property Owner(s): c:1/4-7 fL i va Ps i os: D 12. 60L" -r44 T G N a> 19, 4166(6 <br />Contractor(s) Name: VA S R. 1? orjAT <br />Contract Company Name: _Zo wA'Ti.5 C 0 157 EA.V_ r7 ow <br />Contractor Address: 'J SrAM Ci_ DEz Z7 <br />City: rV1 t 5,1-1 p —A4CA- Phone: (5' 7'/) 25-9 - t3 /y S— <br />Current Use of Building: s t td & LC PAr" 114-Y <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: WWD Fz4 r - i�' <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: n In-kind 0 Landscape New ❑ Replacement (not in-kind) [] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: r c k ono 4n . �S'e2. cWa eADq _&CCn <br />!told !>Pt�J f /r, r,✓- w-s��v'i�c� .S�a _,r +or 69 <br />r <br />Owner/Contractor: Fax: CS--74WJ 2-5_? <t� e-mail <br />(This office will correspond with only one designee) <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />