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Application <br />- FOR - <br />CerHficate of Appfopfiateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />P, sailing Address: County -City Building, S—ab Bend, Indiana 46601 <br />Phone: 574.235-9793 , Fax: 574-235-9578 e Email: SBSjCHPC@co.st-joseph.in.us <br />Website: http://wmv.st osephcouiityindiana.mm/s chp/hidex.html <br />01-TICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CON14INED IN THIS BOX »»» OFFICE USE ONLY <br />Date Receivedin. 1 10 Application Number aO / D - A-204109 <br />Past Reviews: [ �S (,nate o/Last Revic,tn)-um -OINI E]NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />❑ Local Landmark [� Local Historic District (Nance) ,u r <br />[] National Landmark E] National, Register District (Natne) <br />Certificate of Appropriateness: ` <br />R Denied F]Tabled R Sent To Committee ❑ Approved and. Issued <br />DATE <br />Address of Property for proposed work: <br />Street N�urrtm%bi. d qtr f Natne <br />Name of Property Owner(s): (Please Print) dos e, <br />Address ofProperty Owner(s): <br />i <br />Contractor(s) Name: Pen d "? 4 <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building:��� <br />(Single Family - Multi -Fe utily-Cvaierd7l-Gowrnmeit _'Industrial-114catd - etc.) <br />Type of Building Construction: WLtceW Ir-ai17 -L <br />("boil Frame - Brick - Stone - Steel - Concrete -Other) <br />Proposed Work: (] In-kind R Landscape [l New [R replacement (not ithkiutf) n Demolition <br />(more than arse box may Ix, checked) <br />Description of Proposed `Work: __ r% / <br />• i, � J.r.7i YZr. C�r,4�% h t �n � Whi 7�z Jy1s� Dt2 ��'c: ,� t4.! i ►21� .� <br />M r,ev w bo Quo u 3 t.E- E�XU K. n <br />Ow er/Contractor: Fax:- e-mail <br />(ris ict Willco lNlt I r only Otte csiglw) <br />and/or <br />- — APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />