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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 • Email: SBSJCHPC@co.st-josepILin.us <br />Website: http://www.sgosephcountyindiana.com/s chp/index.html <br />OFFICE USE ONLY »»p» DO NOT COMPLETE ANY ENTRIES CONRINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received /rJ&_ S .7" 9 Application Number <br />Past Reviews: []YES (Date of Last Review) oZ 3 oZ GUS E] NO <br />Staff Approval authorized by: pp Title: <br />Historic Commission Review Date: 20a%� <br />Local Landmark Local Historic District (Name)`�G�%i <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied [] Tabled E] Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work: O rS '� 7( L) �- <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) AA I CA A C. NS C!5 - <br />Address of Property Owner(s): s A frA t_ <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: � 000 T' 2 f�lV\.� <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: r" In-kind � Landscape ❑ New Vf Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed WorkKD 1R6L0CA� �'A�S�C� � c3r'` r At <br />1►'�1 C'� <br />O _3 AIL C, A t-i.tY A ncjE5S %LX A NCI j -' 6A(?A ) <br />i—r �>� _ ` -rh%K� tcy l $11:4(r <br />5sc�t.4(s- 1Fkm 3A tc*k_ Rrl7 1L,�lK� <br />c �S� 1=5 i1 �►Lr cs�t'Z-J�C� �u�`f�'. C7��C�..�t.�v(t—, <br />V< to r-_L.0AY A No, �$LA<-E �i C�R1NSS A.q D I' z62 3%i5 iD? <br />Owner/GaR#acter: Fax: a -mail MiC�l�1�t N �151— X11 Nt`, C00N <br />(This office ce will c7espon4 with only one designee) <br />�--do and/or <br />— APPLICATION REQLHREMENTS ARE LISTED ON REVERSE SIDE — <br />