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A <br />Application <br />FOR - <br />CerH <br />fiCate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46401 <br />Mailing Address- County -City PU;Ielin South Bend Indiana 46601 <br />Phone: 574-235-9798 Fax: 574-215-%78 * ErnaiLSBSjCHFC@cost-josephinuS <br />Websita, httF.//winv.stkmphcountyindiana.cwn/sjchp/index.litml <br />OFFICE USE ONLY>>>>>> DO NOT` COMPLETE ANY ENTRIES COIMINED IN THIS BOX >>>>>> OFFICE USE ONLY <br />Date Received Application Number 011/2 J �lf'E <br />Past Reviews: M YES (Date of writevi=) ❑ NO <br />Staff Approval authorized by: tai Title: <br />Historic Commission Review Date: <br />Local Landmark Local Historic District {Namr) <br />rC ti' <br />National Landmark National Register District Woml <br />Certificate of Appropriateness: <br />Denied [:]Tabled Sent To Committee Approved and Issued DATE <br />Address of Property for proposed work- q_?_ Ll <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Nnt) a -y /* e4 <br />Address of Property Owner(s): <br />Contractor(s) Name: - (f I c- e -?c <br />Contract Company Name: <br />Contractor Address: <br />Phone: <br />Current Use of Building; <br />(single Family - Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Conistruction: K__)Cke-'k <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind n Landscape 0 New n Replacement (not in-kind) [] Demolition <br />(more than one bar may be chased) <br />Description of Proposed Work- <br />cx <br />Owner/Contractor. Fax: e-mail <br />(This cfficr wM corrtspnd mjth on designee) <br />j <br />Xzf%zle5�y ane 1_11111'�r-. and/or <br />— APPLICATION REQ UIREINIENTS ARE LISTED ON REVERSE SIDE — <br />