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i <br />Application <br />- FOR - <br />Certiificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 4(kOl <br />Mailing Address: County -City Building, South Bend, Indiana AAAA <br />Prone: 574-235-9758 + Fax: 574-2335-Tj78 • Email• SBSiCHPMo.st josephin.us <br />Website littr//www.stjosephcountyindiaro-com/Ichp/indmbtml <br />OFFICE USE ONLY»»» DO NOT COMPLETE ANY ENTRIES CONIA <br />tNEL) IN THIS BOX »»» OTI"ICE USE ONLY <br />Date Received 3. 1 0 Application Number lu Q_ - X50 4 A <br />Past Reviews: R YES (ewe o f last &view) <br />Staff Approval authorized by: <br />Historic Commission Review Date:c(� ! 10 <br />[] Local Landmark] Local Historic District (Name.) nyl�1 <br />[] National Landmark [] National Register District (Name) <br />Certificate of Appropriateness: <br />YNO <br />Title: <br />Denied ❑ Tabled ❑ Sent To Committee F1 Approved and Issued <br />9^ <br />Address of Property for proposed work:. / I--- lbw <br />Street Number and Street Name <br />Name of Property Owner(s): (Pique Print) --�4^ P <br />Address of Property Owner(s): 7/ <br />Contractot(s) Name: <br />Contract Company Name: <br />Contractor Address: ') <br />V <br />DATE <br />City: _.- : = �1— A Il777A! _ Phone: i `7 Y _ U - , <br />Current Use of Building: <br />(Sing)s'amily - Mu11i-Fami1y - Co merdai - Government - Industrial - Vacant - etc.) <br />Type of Building Construction:�+r01 7riz Amp <br />(Wood Frame -Brick - Stam - Stmi - Concrete- Other) <br />Proposed Work: W In-kind E]Landscape [❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more titan one box mazy be chtz9ceai) <br />Description of Proposed Ark:,..... + . �I; t ; .. � ( � � r F <br />Owner/Con . o Fax:_ `-. y q/) e-mail ��� -�, r� � � r, r ApJ jE <br />, <br />( ' olf,m Yngvn *h only one deaigne) ( � <br />/?jIt lt�) 12 5ft7+trrtl/�sC r <br />Il and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE -- <br />