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Application <br />-FOR - <br />Certi ficate 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: 574-235-9798 • Fax: 574-235-9578 • Email: SWC 1PC@co.st joseph.inus <br />Website: hq://www.st osephcounqindiana.com/sjdip/hidexhtnil <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANYENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received of oZ0 /O Application Number c9D 14 - 04 404 <br />Past Reviews: ❑ YES (Date of last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark [ focal Historic District (Name) fAZe� <br />National Landmark R National Register District (Name) O <br />Certificate of Appropriateness: <br />[] Denied E] Tabled E] Sent To Committee Approved and Issued <br />Address of Property for proposed work: <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): 55 <br />Contractor(s) Name: N.�.�.�^_ f <br />Contract Company Name: /V a "4 - <br />Contractor Address: ISI 0—k- <br />City: <br />Current Use of Building: <br />Type of Building Construction: <br />DATE <br />J55 3 AVB. <br />Street Number and Street Name <br />S�e../en �wr fz <br />Phone: f47 6e,11; .630 7a8 5996 <br />(singe Family — Multil milt' — Commercial — Government — Industrial — Vacant — etc.) <br />FJo�rAC. <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: r-1 In-kind E] Landscape [2 New ® Replacement (not in-kind) [:] Demolition <br />(more than one box may be checked) II I'Ablt- <br />Description <br />of Proposed Work: `�/o cti'r� 1� Ov\� ri2�,1 c�'�lr,;h u1r'� ) <br />411k%511 411 Drrn wi'AtAWS ()vx .41y4dw5 gn 0i -5r- lO re'01A"_' <br />Owner/Contractor: Fax: <br />(This offxe will correspondwith only one designee) <br />skxl-\ I� v 2 <br />'1b <br />new At r"S nh� r G�t b13t+�� & s.wc aIJ <br />e-mail 5 �v��(�Z c. JY\ A . CGl V� <br />and/or <br />— APPLICATION REQLIIREIVIENTS ARE LISTED ON REVERSE SIDE — <br />