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Application <br />-'FOR - <br />Certi f icate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 & 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: SBSJC B PC®m.st josephmus <br />Website http:// www. stjosephcoungindfimc om /gchp /indexhtml <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received . / 79AUt e20/0 Application Number a D /0 <br />Past Reviews: EaAS (Dare of wt Review) oZq ?Xut. L t2" 7 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: / 9 . 020 / 0 <br />❑ Local Landmark Dcal Historic District pvame) Y,tJ- 720 <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: 4A Nov iV c� Xote— h r�� <br />Q f Stree Number and Street Name > <br />Name of Property Owner(s): (please Print) -�- <br />Address of Property Owner(s): 0/ �Jc Aln-A Slime. A <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: _/ //�� _ Phone: <br />Current Use of Building S irr0 / _ 1 h F2 f «'/E' G <br />(fingle Family— Multi - Family — Commercial —Government —Industrial —Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: n -kind ❑ Landscape [:]New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box my be ducked) � � � <br />Description of Proposed Work: �Ql/` OY 0 ir1r1 E.� H-12a 'fl <br />lCJ GA" <br />E /Cat <br />Owner /Co c r. Fax: �, 31 e -mail <br />(This office d on one nee) v <br />and /or - <br />— APPLICATION REQ UIRF.MENTS ARE LISTED ON REVERSE SIDE — <br />