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10 <br />Application <br />-TOR - <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: 574235 -9798 • Fax: 574235 -9578 • Email: SBSJCHPC@co.st josephin.us <br />Website http:// www. sgosephoDungindiana .com /gchp /index.html <br />OFFICE USE ONLY > >>> >> D�O� NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received "^7" °Z GAO Application Number ° o / U - o �C/ 5 <br />Past Reviews: [FEES (Dare o /tst•xeow) 02 UGC • 01415 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />❑ L.ocaltandmark ❑v'�eal Historic District (Name) G• <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled . ❑ Sent To Committee A Approved and Issued <br />DATE <br />Address of Property for proposed work: f 11J my q E_ 5 .r t~. <br />Street Number a Street Name <br />Name of Property Owner(s): (please Print) <br />Address of Property Owner(s): / Y k_x. S . <br />Contractor(s) Name: � ��� ' U � 1 12 kXV; <br />Contract Company Name: ��►I t? ck + i dx <br />Contractor Address: _� 1.� S o A k. <br />City: .S G :� ��� t' ��.� Phone: J��`� '` � q 9 7 <br />Current Use of Building: S : V e'1 ci � i <br />(Single Ally — Multi- Family — Cont'inerdal — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: R l , C e <br />(Wood Frame — 11 id, — Stone — Steel — Concrete — Other) <br />Proposed Work: V In -kind ❑ Landscape ❑ New ❑ Replacement (not in -kind) ❑ Demolition <br />(mare than one box may be chcdced) j <br />Description of Proposed Work: 7 e i%,�_+ b r c. i � ['I tL e s_ f 5 <br />e� e _ cis e �/�`�" f' v' S �t'l� Cn r.t'1� r1 Z rx !� �' L ca cx it e �t tl ►�'• <br />V �jj i- 4 <br />P�t'T` rt tv re'.erf of er��'LeN CAiluO_ j ilk C'�el Phi I <br />�-- -{- 4? C, ek . O Iv i vk, <br />V <br />Owner /Contractor. Fax: ' 7) — .1 7 e -mail <br />(This o tcA correspond with only one desig16) <br />and /or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />