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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: Counfy-City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax: 574-235-9578 • Email:- SBSJCIBr, 0.Stjosephlnus <br />Website: http://tmwstiosephcountvindiana comisichpl <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS <br />BOX »»» OFFICE USE ONLY <br />Date Received o--ov % Application Number <br />Past Reviews: [EYES (Date of last Review) <br />Staff Approval authorized by: <br />9�%a�r– A" `3 E] NO <br />Title: <br />Historic Commission Review Date: 02/ ,p <br />Local Landmark [R'foeaI Historic District (Name) G - <br />n National Landmark [] National Register District (Name) <br />Certificate of Appropriateness: <br />Fj Denied E] Tabled Fj Sent To Committee Fj Approved and Issued <br />DATE <br />Address of Property for proposed work: :l !:467 <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): <A1111C <br />Contractor(s) Name: A`_A/-) A, <br />Contract Company Name: ,CA,57 Tf t;C 77A �- <br />Contractor Address: <br />City: <br />Current Use of Building: <br />Phone: Zi <br />mgi,tamily : Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame Stone — Steel — Concrete — Other) <br />Proposed Work: In-kind ❑ Landscape [] New (R Replacement (not in-kind) ❑ Demolition <br />(more titan one box may be checked) <br />Description of Proposed Work: <br />i�-t7Cilil�� �L'fiic^tc�l�1 ,j1-171 P64,F) ✓U �3 <br />I <br />Owner/Contractor: Fax: 'l15 s %%• �'� e-mail_ <br />(This office will correspond with only one designee <br />R <br />L��x , ' � / and/or - <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />