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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 466(}1 <br />Phone: 574-235-9798 • Fax: 574-235-9578 • Email: SBSJCHPC_@cost josephin,us <br />Website: http-//www.sqosephcounqindiana.com/s chp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONT WED IN THIS BOX »»» ONCE USE ONLY <br />Date Received 8 Application Number <br />Past Reviews: GKES (Date q Last Revtetu) 7X7 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: C2 i 3 <br />C1 Local Landmark . 2'tocal Historic District (Name) r ► <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:! y 4 l LS l <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) UN -n -7 Z. <br />Address of Property Owner(s): 1 U I 'I r• <br />Contractor(s) Name: ` f� �(`l—t rr <br />Contract Company Name: -P 1�)i 1_A- <br />Contractor Address: 13 nC l -t --0(Lf t P Ll <br />City: LA i _ 4lha Ln to h <br />Current Use of Building: <br />Phone: r-1 "144 <br />Q V Q.- !�r� 145� <br />r�-)i ne_.n ins <br />(Singe Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: �.A � tUCX�� <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: F] In-kind [] Landscape ❑New Replacement (not in-kind) <br />(more than one box naav be checked) e . <br />Description of Proposed Work: <br />40 <br />tA,( <br />rel <br />nn Ic c7c <br />❑ Demolition <br />Owne in Fax: rla`1'� ' .41 r1 ' ri Wr r - e-mail <br />(This office tul tuith edesigtee) 6-�`,�(� <br />����.C%� and/or. <br />— APPLICATION REQ(HRSMENTS ARE LISTED ON REVERSE SIDE — <br />