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A <br />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: 574-235-9798 • Fax: 574-235-9578 • Email: SBSJCHPC@co.st josephin.us <br />Website http://www.sgosephcountyindianarnm/sjchp/index.html <br />OFFICE USE ONLY»»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN 77ffS BOX »»» OFFICE USE ONLY <br />Date Received ago / O Application Number 4 0 <br />Past Reviews: Eq-fES (D.,,gLast-R.ew) o-4 Ae, Z07 7 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: 16- 22CA t t 4 OW /O <br />® Local Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee, ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: 61' I ! 0,5'31 S. -SO u A�A _No — � JE� <br />n ��I, 'llS��treet Number and Street Name <br />Name of Property Owner(s): (please Print) Gain �t 6 4P <br />Address of Property Owner(s): ' C11 91 US .731 _S r� <br />Contractor(s) Name: _& t`«x <br />Contract Company Name: <br />Contractor Address: r) <br />City: M ►s hvL✓ c 11N'Ci' .1N V�.f-q i Phone: <br />Current Use of Building:_DFC-4L' SQn <br />ce- <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: & iC k <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: ❑ In-kind ❑ Landscape [(]/New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) Q <br />Description of Proposed Work: 1 ��i - MOAO O?K_ - '<k1 r, <br />Owner/Contractof Fax:) 571- S .S- 11 e-mail brill N in '�'�it'nson, r) C t 1_/S fjoj <br />(This office will correspond��vitaakerrly one designee) <br />X�Y1A ice.^u_ and/or - <br />— APPLICATION REQIHREMENTS ARE LISTED ON REVERSE SIDE — <br />