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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: 574-235-9578 • Emaih SBSjCHPC@co.st-josephin.us <br />Website: http://www.Sgosephcountyindiana.com/s chp/index.html <br />OFFICE USE ONnL/Y »»N»IDO(�NOT COMPLETE ANY ENTRIES COAMINED IN THIS BOX-- OFFICE USE ONLY <br />Date Received . la R, 001 Application Number a o v - 05i <br />Past Reviews: ❑ YES (Date of Inst Review) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />❑ Local Landmark [✓Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />N • <br />Title: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: 3) 1 w. [ &'&r r( -e. <br />N . Street Number and Street Name <br />Name of Property Owner(s): (Please Print) J a5ii n Ch n &- en se n <br />Address of Property Owner(s): (e - %14" f lwd I N Li D I 0 I (.0 <br />Contractor(s) Name: .SNp_ Kb( (IS <br />Contract Company Name: 8DLk V" __e� C/�f�rn��lQ-{-D� <br />Contractor Address: 11&5 �(_v1 �( % � On -k IL -w'. <br />8 <br />City Q10A IS" 1 I N I,: - Q, 1 -7 Phone: _ 5 -7 Li LQ 3 3 a'aN <br />Current Use of Building: 1_� 1a.:h ` 4? ! <br />(Single Family <br />r—Multi-Fanfl�— Commercial —Government — Industrial — Vacant — etc.) <br />Type of Building Construction: W0ca Wc_e_ <br />(Wood Frame - Brick - Stone - Steel - Concrete - Otlwr) <br />Proposed Work: ❑ In-kind Plandscape [ 3*&ew ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be ciwcked) <br />Description of Proposed Work:� VA Q6 V ar 1.! . n �,�'� <br />ner ontractor: Fax:5�3 � 3a a e-mail'i'i-i CkQ x(1'10.* . G�� <br />is "'will comes u h only one i nee J <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE <br />