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Fran: 06/15/2010 11:41 #973 P.005/005 <br />OM = <br />CerHficate of Appropriateness <br />Historic PM-A - mtlon Commission of South Bend & St. Joseph County <br />225 S. Lafayette Blvd., South Send, Indiana 46Wl <br />Mailing Address County -City SuBding South Bend, Indiana 46f}1 <br />Phone: 574 -23raA M - Fa:c 5'74- 235A57$ * Email: SBSjC 1PC@cost jc h in us <br />Website: httg. / /wwwsgoscph=nVhuUamcom /s chp /index -html <br />OFFICE USE ONLY - -> "" D__O NOT COWIXrE ANY ENTMS CoNnrVED IN IMS BOX OMCE USE ONLY <br />Date Received 1 '� +ma 24 /43 Application Number <br />Past Reviews: Q''?u {rz trcitnsr aeor�} 'S�� , <br />Staff Approval authorized by- <br />Historic Commission Review Date: <br />Local Landmark <br />National Landmark <br />[tRt? cal Historic District {Name) <br />National Register District tNmnet <br />Certificate of Appropriateness: <br />• <br />Title: <br />Denied ❑ Tabled (l Sent 1b Committee ❑ Approved and issued <br />DATE <br />Address of Property for proposed work: n( )LA <br />2 — N u Name of Property Owner(s): (Ptease Print) } t�� <br />Address of Property Owner(s): �' �~� (_�� ti .n O r <br />Contractot(s) Name: <br />Contract Company Name: ,( , { <br />Contractor Address: <br />City: _ @ <br />Current Use of Building: <br />( Single Fcmity- Mufti- Fam&y- comnrrttaI - cam rrnrcrnt - t riot - Vacant -rtr.) <br />Type of Building Construction: <br />(Wood Fraw - Brick - Stone -Stmt - Concrer- Other) <br />Proposed Work: ❑ in -kind [] Landscape 0 New KReplacement, (rot in -kin) F Demolition <br />Om one bax may be dwtW) F <br />Description of Proposed Work: t 1 /P -` <br />Owner/Contractor. IF 1 e - mail <br />(Th , j(�, fly ? � �� 1111 L • I+�Gt <br />is afx tell! carmvonct with only one drsirree) <br />and /or <br />— A PPLICA77ON REQUIREMENTS ARE 11STED ON REVERSE SIDE — <br />