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0 <br />Application <br />- FOR - <br />Certificate icate o f Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Halling Address: County City Building South t3cn4, Indiana 4&101 <br />Phone: 574-23-1-9798 - Fax: 574-2.35-9578 - Email: SWCHPC@co st josephJn.us <br />Website: http://wwNvstioselihco=nt diana.com/sjchp/indexlitnil <br />OFFICE USE ONLY »�»» E DO NOT COMPLIT ANY F,WMIES CONTAINED IN' 771IS BOX »»» OFFICE USE O1VLY <br />Date Received'y. �� 1 Application Number � � � - 0 to �i A <br />Past Reviews: [] YES (Cate e; Last Review) <br />Stasi Approval authorized by: <br />Historic Commission Review Date: <br />E] Local Landmark 'Local Historic District (.Dame) <br />National Landmark C] National Register District (,varve) <br />so <br />Title: <br />Certificate of Appropriateness: <br />R Denied F_� Tabled ❑ Sent To Committee Fj Approved and Issued <br />DATE <br />Address of Property for proposed work: t7 cs ` 4cte-Ap" <br />Street Numbc7 and Street Name <br />Name of Property Owner(s): (Please Print) W'�(i a Af" :' tZ*rlL VWK- <br />Address of Property Owner(s): Cg i'j _ � t � �7 ti7 t4) 7 g � ` Z q ; o <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: Plione: <br />Current Use of Building: <br />(Single Family — Wti-Family — Commercial — Gwvernment — Industrial — vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Slmae — Steel — Uncrrte — Other) <br />Proposed Work: E] In-kind (21 Landscape E] New ® Replacement (not in-kind) ❑ Demolition <br />(mor :soars nr,e%x tnay Ike cdu*cl� el) �} _. _._. <br />Description of Proposed Work:�.� <br />Owner/Contractor: Fax: e-mail <br />(MI o(fxe will u€rresrhartd with only one drs �rur) <br />and/or <br />— API'LICATION REQUIREMENTS ARE IJSTED ON REVERSE SIDE — <br />