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_0 <br />14 <br />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 />Maili ng Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574 -235 -9798 • Fax: 574 - 235 -9578 • Email: SBSJCFTC@co.st-joseph.in.us <br />Website: http: / /www.st osephcountyindiana .com /sjchp /index.html <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received ao fa& oZO/O Application Number <br />Past Reviews: ❑ YES (Date of Last Review) [:] NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark F1 Local Historic District (Name) <br />National Landmark F] National Register District (Name) <br />Certificate of Appropriateness: <br />Denied [] Tabled F Sent To Committee F Approved and Issued <br />DATE <br />Address of Property for proposed work: O l a Le, 4 " a 4 e <br />� /� / S et Number and Street Nale <br />Name of Property Owner(s): (Please Print)' / o An f� • l �n <br />Address of Property Owner(s): <br />Contractor(s) Name: �✓ �� <br />Contract Company Name: <br />Contractor Address: <br />G M d <br />JZ7 ,( <br />City: Phone: <br />Current Use of Building: �' � ,t /t r. • �y <br />(S(gle Family - Multi - Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: /--& s e " <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Description of Proposed Work: <br />Owner /Contractor: Fax: e-mail . �A / o t All S • �/►1 <br />(This office will correspond with only one designee) <br />and /or <br />Proposed Work: ❑ In -kind E] Landscape New E] Replacement (not in -kind) [] Demolition <br />(more than one box may be checked) <br />— APPLICATION REQ=MENTS ARE LISTED ON REVERSE SIDE — <br />