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Application <br />Application <br />-FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & SL Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing <br />AAA --00: Building,CZ--+k Rn"el TnA;nnn 46601 <br />Phone: 574-235-9798 - F= 574-235-9578 - Email: historic@n-dchiana.oxg <br />Website: http://commurdty.rrddiiana.org/bistoric/ <br />A Certified Local Government <br />OFFICE USE ONLY >>>>>> DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX >>>>>> OFFICE USE ONLY <br />Date Received /J At 07416 Application Number a0_110 -1614 <br />Past Reviews: r-1 YES (Date ofLast Review) <br />Staff Approval authorized by: <br />70170 <br />Title: <br />Historic Commission Review Date: /X lqer� d <br />Local Landmark 1311:_O'Cal Historic District (Name) <br />National Landmark M National Register District (Name) <br />Certificate of Appropriateness: <br />M Denied E] Tabled M Sent To Committee M Approved and Issued DATE <br />Address of Property for proposed work: M (4ccr <br />Street Number and Street Name <br />Name o I f Property Owner(s). (Please Print) t-/ b L -A -pi im LIM 7 <br />1\)A- 9�6 <br />Address of Property Owner(s): ILM1 V-4 / <br />Contractor(s) Name: S� <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: <br />(Single Family - f5lti-Family 40mmercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction. <br />Wood Frame Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: F� In-kind [—I Landscape _C72ew [�6eplacement (not in-kind) Demolition <br />C El <br />(more than one box may be checked) <br />Description of Proposed Work: 06 P (_ u T -F n-44 FF o P () Gb Roo r— <br />L-Pq? j2 AI4, 1\) &r, e_-tj, 4, AR__� REPLAtc W -AP eDI-C- 6D C) %-A3 In t <br />t,A-) ATE; i f I gt-,b �r_ c 141 rFZ tv Ph L 14-1 <br />A,1-1) ow tn-04.1, <br />C1 I ` /Cont ctor. Fax: ,A e-mail <br />Wn= <br />(n4 is q;e corr and zoith one designee) <br />and/or <br />Signature of Owner Signature of Contractor <br />— APPLICA77ON REQ MMMM ARE LISTED ON REVERSE SIDE — <br />