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Application <br />- FOR - <br />Certi <br />fixate <br />of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />MA111Ib V Building, South Indiana 46601 <br />Phone: 574-235-9798 * I= 574-235-9578 * Email: SBSjCHFC@co.St-joseph.iTLUS <br />Website: ivww.sqosephcounVffidiana.com/sjchp/indmhtrrd <br />A Certified Local Government <br />OFFICE USE ONLY >>>>>> DO NOT CQMMM AbOLE&TWS CONTAINED IN MISRU>>>>>> OF17CE USE ONLY <br />Date Received 20/ Application Number !o 1r) too/ <br />Past Reviews: 0 YES (vat, of Ixt Revkw) NO <br />Staff Approval authorized by. Title: <br />Historic Commission Review Date: /9 oe'r >_O/a <br />Local Landmark Local Historic District ovame) <br />[]National Landmark National Register District Watne) <br />Certificate of Appropriateness: <br />RDenied RTabled [:]Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work. 4e, <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print e <br />Address of Property Owner(s): KVI <br />f <br />Contractor(s) Name: jj:T_0' 776 g4!"'4_c <br />Contract Company Name: <br />Contras r Address: _15-6 rx2p <br />City:,,,�A -Phone. <br />Current Use of Building: <br />Multi -Family - Commercial - Got-ernment - Irdustrial - Vacant -eta} <br />Type of Building Construction: <br />�Fwme' Brick - Stone -Steel -Concrete -Other) <br />Proposed Work: n In-kind Ej Landscape 0 New ,Replacement (not in-kind) [] Demolition <br />(more than one hax may be chedxd) A <br />Description of Proposed work-_:" � �� = <br />lue <br />Cwne_rf ontracior. Fax:,, 7' � --z--.3 03 e-mail icolL te'v4/o1cL <br />" designee) <br />'o 'On <br />Z and/or <br />' 7e Z"Z s4atux-41of Owner Signature of Contractor <br />T" <br />E SIDE -- <br />ZI <br />Ll <br />