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Application <br />- FOR - <br />Certificate of Appropriatetiess <br />Historic Preservation Commission of South Bend K, St. Joseph County <br />125S. Lafayette Blvd., South Bend, Indiana 46601 <br />"nuir Address: County -r-. R"Od""fy Scmqft <br />b -nAI IndianaIndianaAAAnI <br />Phone: 574-235-979$ - Fax: 574-235-9578 * Email: SBSJCUIPCk-�co.st-jo,-,c-ph.iii.us <br />lVelr+ite:littp://it-wwstjoseplxountyinLiiana.com/sjchp/ind ex.htnil <br />OFT -ICE USE ONLY »»» DO NOT COAIPLETEAi%'YLiNTRIE,5CONI [NEI) IN 7711S BOX >>>>>>OFFICE USE ONIY <br />Date Recejved_4��_a. —41-016 Application Number - /e0 4CC-1 <br />Past Reviews* E] YES Wnr of 1P.0 Mift-w)� . ..... ­­ DR -KO <br />Staff Approval authorized by: <br />1-Itle. <br />Historic Commission Review Date: / <br />Ej Local Landmark Fr -l' -Local Historic District (,vame) <br />[] National Landmark &Natlonal Register District VN14mr) <br />Certificate of Appropriateness: <br />E] Denied ❑ Tabled E] Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work.--& '13(:7 XW7X6"_a <br />Name of Property Owner(s): Qlw,�, Print) 1�y4c.4 <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, _04W (.1,44 vvL/711j11171_# <br />Viawni —ek.) <br />Type of Building Construction:-Z"e/ee V jvA':P'� <br />(i&,d Fmme — Frisk — Stow— Steel — Coracle — Other) <br />Proposed Work: [] In-kind n Landscape Ej New Ej Replacement (not in-4,ind) Demolition <br />(r A. tan etre ki m�y IV duyh-d) r- <br />Description of Proposed Work: l) � -0 (ff I IT <br />tLN Wo j7AP_�06, AVAILN31-C <br />We Wilt IX�lCtL-MP_ {mut! alt hNbWOMN11,4 wTIA4 <br />6"QP66 - - I <br />Owner/Contractor., Fax: <br />_67'0 and/or <br />.. . ..... . . .............. . ....... <br />— APPLICAT70N REQUIvE.MENTS ARE LIM'D ON REV'FRSE SIDE -- <br />