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Application <br />I FOR - <br />Certificate of Appropriatettess <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd, South Berd, Indiana 46601 <br />t-r- A4MI <br />Mailing Address County Bus —w-,, So uth — <br />Phone: r)74- 2i,5 -(m - ra)c 574 - tmail: hrtond O T <br />Website: lhttp,/ /cormuniqumidiana org/historic/ <br />A certified Local Government <br />0HICE M OIVLY ">>>> DO XQT CQMP= AM LITMIES CQNTALVID- 1I <br />IN U5J= >>>.->> 01710E USE ONLY <br />Date Received-.4 �x .20/0 Application Number !4 <br />Past Reviews FrVU (NIecILmtPer*w) Wy ❑ NO <br />Staff Approval authorized by: <br />Historic Commission Review Date! ? 16 <br />f Local Landmark <br />] National Landmark <br />MI;cal Historic District Wome) <br />[] National Register District Wamr) <br />Certificate of Appropriateness: <br />Ti <br />0 Denied DTabled ❑ Sent To committee E] Approved and Issued DATE <br />Address of 'Property for proposed work: L0 At"C-7 &--, 1 <br />Strom Npmber as Street Name <br />6 <br />Name of Property Owner(s); (Pk Print) J. )0 14 <br />Address of Property Owner(s) <br />Contractorfs) Name. /I <br />Contract Company Name: <br />Contractor Address: <br />City. Phone; <br />Current Use of Building: <br />(single Family -Wt� ity-CV=UTCi,71-Gaymmmi-Imhatr&I-V"vnt-dc.) <br />Type of Building Construction: A-IQ0 " <br />(wom.Framr - Brick Shw. -Sitri - C.-'de - Other) <br />Proposed Work. ] In-kind. ❑ Landscapegt4,w E] Replacement {not m -kind) E] Demolition <br />(nxm than one box may br dwdM) <br />Description of Proposed W0dc-,,A <br />L 'lx� ' fTfs1� 71�r�ts -C� t fIf � r'o,m.rt 7a_ 'ant 5f�j►r.,�.t �itJ/!rra'� wx �3,+:. kT �i; r"�•*Y� <br />g6x, 7 ggzg <br />'CiwnWContrattor. Fac e-mail <br />�ui aoit ant goer) <br />arid/or <br />Slrfatuar o <br />Signature of Contractor <br />r,,, t� <br />0 <br />AppuC47TONREQUIREMUM ARELISTM ONREVIMSE SIDE <br />