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Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & SL Joseph County <br />115 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Ma€ling Address: County -City Building, South Bend,.Ind€ana 46601 <br />Phone: 574-235-798 Fax: 574-2-9578 Email:-SBSjCHPC@costjosephin.us <br />Website: http://wwwsgoxThcountyindiana.com/sidip/index.htnil <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE <br />ONLY <br />Date Received o r OW10 Application Number / 1�_ - d -1-z l <br />Past Reviews: n YES (Date of W1 Rmkw) <br />Staff Approval authorized by: <br />■ • <br />Title: <br />Historic Commission Review Date: a2/ C'7' 41 <br />Local Landmark 21ocal Historic District (Natnt) __j:5 IZ)4 +P .�.. ufiZ <br />National Landmark n National Register District (Name) U <br />Certificate of Appropriateness: <br />❑ Denied F� Tabled [] Sent To Committee C] Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />P p P , V '�- le <br />Stree Nurnhtr <br />trttt Name <br />Name of Property Owner(s): (Pteaw Print) __M- (�J..�V, b /1ju <br />Address of Property Owner(s): 17,`7 'C� t") 11 TIJ <br />J <br />Contractor(s) Name:i <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: a t n� <br />(ShgleFamily —Mut -Family—tonnercialGowerument—industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frante — Brick — Stone — Sart -- Concrete — Other) <br />Proposed Work: E] In-kind [:] Landscape n New replacement (not in-kind) [] Demolition <br />(*nem liar orxr baz. nxy berh=kcd) <br />r >� <br />Description of Proposed Work: 1,45 <br />cA <br />Owner/Contractor: Fax: e-mail Is�P')-- r77 <br />(This cfficn will mrrevend with onry one designee) <br />and/or <br />— APPUCA774N REQUIREMENTS ARE LISTED ON REVERSE SIDE -- <br />