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WN. <br />3-pplication <br />- FOR - <br />Certificate of .A.ppropriateiiess <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Fiend, Indiana 46601 <br />Mailing Address: County fifty Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fac 574-235-957$ • E-maiL-SWCfiPC@co,st-josEph.in.us <br />. Website: Nvww.sqosepheountyindiaina.com/sjchp/indt-,x.hftnl <br />A Certified Local Government <br />OFFICE USE ONLY »»» PO NOT COMELEffLANY FNiRIES CONTMI MN THIS BOX »»» OFFICE USE ONLY <br />Date Received I © ZDia~t Application Number 2 � -f0 - 400 JA <br />Past Reviews: E] YES (rweof z sr t2rricrn) [R -NO <br />Staff Approval authorized by: Titles <br />Historic Commission Review Date: <br />F] Local Landmark [�ocal Historic District (Name) <br />[� National Landmark � [DNational Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied [] Tabled n Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: <br />(Single family - Multi -!'amity - Commercial - Gommment - Industrial - Vacant -etc.) <br />Type of Building Construction: <br />(Wood Frame -• Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: [j In-kind C] Landscape C] New (] Replacement (not in-kind) [] Demolition <br />(more than one box may be checked) L <br />Descrifp�tion of Proposed Work: � �`� �',-f �',"'7'.�044- 4 r"-i1� � � �=��`*--� 7&4"L-- <br />Owner/Contractor: Fax e-mail <br />(Thisof ' ill lxmct d only one designer) — <br />and/or <br />Signatture of Owner Signature of Contractor <br />— APPLICATION REQ UIRER1EM ARE LISTED ON REVERSE SIDE -- <br />