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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 />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574235-W% - Fax: 574235-9578 - Email: SBSJCHPC@cost Joseph in.us <br />Website: http://www.sqosephcounVindiamcom/qchp/index.hbnI <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CON -P PTD TN THIS BOX —» > OFFICE USE ONLY <br />Date Received / 1" a0lD Application Number o? 0 LO - - OGO / <br />Past Reviews: [✓] YES (Date of Last Reuk.) ! ,% %?Yd4, 40/0 ❑ NO <br />Staff Approval authorized by: C�e� />� - Title: <br />Historic Commission Review Date: <br />❑ Local Landmark 21. oval Historic District (Name) <br />National Landmark [RNational Register District (Name) <br />Certificate of Appropriateness: <br />F] Denied M Tabled ❑ Sent To Committee []approved and Issued / lapae dold <br />DATE <br />Address of Property for proposed work.$ 103 <br />RIO <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) 1� O SQ11j, (7.1 a,,,.. V <br />Address of Property Owner(s): <br />Contractor(s) Name: r_ a v <br />Contract Company Name: .cr r Z3j0. <br />Contractor Address: 14� <br />City: ��� 1 ; c AtcL, . X�416.31 Phone: S '0 10— <br />Current Use of Building: 17'r. FOA—.r <br />(Single Family — ul ' m�1y — ommercial ment — Industrial — Vacant — etc.) <br />Type of Building Construction: �/ /Bo V W1_0_ <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: ❑ In-kind Landscape New Replacement (not in-kind) E] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />Owner/Contractor: Fax: 26q s --e-mail <br />(This office will correspond with only one g r <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />