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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: 574-235-9793 Fax: 574-215-9578 • Email: SBSJCHPC@co.st-joseph.in.us <br />Website: http://www.sqosephcoun4indiana.corTi/sjchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONDIINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received atop Application Number a <br />Past Reviews: [B ES (Dateu(tn+t Rerlw) <br />Staff Approval authorized by: <br />3Q 7Y� oZOO, -- n NO <br />Title: <br />Historic Commission Review Date: <br />Local Landmark 191hocal Historic District (Nasne) <br />National Landmark National Register District (Narne) <br />Certificate of Appropriateness: <br />Denied [] Tabled Sent To Committee E] Approved and Issued <br />DATE. <br />Address of Property for proposed work: --ml- ISIvf'(t` S(U yr ' <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) .J't 1 t <br />rint) .,r� tVk",� r 1� (l V Y'eAt <br />Address of Property O/ Iw_ner(s): 1�` ` 1 Ic �P/�lSl (✓ �i <br />Contractor(s) Name: l . VI ViSC3�t <br />Contract Company Name: <br />Contractor Address: �' �g M ad i sdn �1 <br />City: '�* Lvb' RP' lit A Phone: 574- J g q - FU " Y q -7 s <br />Current Use of Building S(�r�, �� ►_ 1 `% <br />(Single P udht -Multi-Pomilp - Cmnn+ereial - Government - bufirstrirr! •- Vitrmd =etc.) <br />Type of Building Construction: M vM \ n V ll1'' S l d i <br />(wood Framr - Bnck - Stolle - Steel - Concrete - Other) <br />Proposed Work: E] In-kind n Landscape f-1 New .Replacement (not in-kind) [] Demolition <br />(mom than one troy may be checked) <br />Description of Propo d Work: ?,g, ( `a C e M t O Wi RA OW S A A _i1.,, �y� a'vv� <br />_(AVi(�. `DDYS �� � 1hv+bt2t Ul <br />Wma W n bmi s <br />' a*dMA AnUmt&" <br />Owner/CefftmctSr: Fax: J'_�91 a-mailJ �y_Wiavo r, mai • ftw-� v <br />(Thi, of/ice will corn•sPOud with nnh/ rnrc &1i,quec) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />