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9 <br />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 />11Lacilirrzg Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax 574-235-9578 • Email: historic@michiam org <br />Website: http://commi nitymid-dam.org/historic/ <br />A Certified Local Government <br />J <br />OFFICE USE ONLY»»» j70 N07'COMPLETEAA1Y.ENN7MS CONTAINEp iNTHIS BOX »»» OFFICE USE ONLY <br />Date Received %r 7X -01Y 0700 Application Number OSLO 5 <br />Past Reviews: [►' ES (Date of t ast Revicu+} I _ a B ❑ NO <br />Staff Approval authorized by: Title:_ <br />Historic Commission Review Date: f� <br />[] Local Landmark [✓]'Local Historic District (Name)'`` <br />[] National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />[] Denied [] Tabled Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: 3©� S' TMJ ►.Eti . ��.,✓lam <br />Street Niunber and Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Pxo --f-Owner(sk 3o4 <br />b • ?rrJ`('t F I l�r tom! p�'��='- <br />i <br />P <br />Contractor(s) Name. <br />Contract Company Name: seorT 4. Sari cod 6rPk-nod <br />Contractor Address: 20910 L,6015E_ 1 --ti l✓ <br />City: �ac1 f!}f 70 <br />! >� `��P(Q t� Phone: 2.1 ` 2 71Ce� <br />Current Use of Building: 5 ►r1lsE. 1-�1ri►[,`(� <br />(}Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: ►"/ ooh''h 1t� <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: In-kind Landscape M New Replacement (not in-kind) p Demolition <br />(more than one Eos may be checked) <br />Description of Proposed Work: t4'-rfrtorf r" r-17u4i5rf f6- t/-�GLcrAE- 'tom' P t <br />afr Eac(5rr rt (� .t K-+ (F-r•f Tlw Pc t% (D �`tot.tTMV t ri A- 14 rel 1: 60 64ff <br />17IM cor- D-1HI 6, POR -4Z rlvc� pol✓1 ;f Hal 1-0 <br />ct5t/N�ovtt frttitic�`'( �.�ht-<- aF,.tsrrrfc• &i`Mt-.� c� ca�r<.x��;. <br />Owner/ ontractor. Fax 574 • & 3I. 500- email tLe,o c.-- 9t ms`s t--3 t46'"J <br />(17ris uri11 c A only o=desikYo �t l yt`� Glt-- tot-764.1900� and/or owrlwts o ic,,= 574•651•!`40 <br />Signature of Owner Signature of Contractor <br />