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Application <br />- FOR - <br />Certif icate of Appropriateness <br />Historic Preservation Commission of South Bend & St, Joseph County <br />125 S. Lafayette Blvd, South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574 - 235 -9798 • Fax: 574 - 235 -9578 • Email: SWCHPC &ost josephin.us <br />Website: hV: / /wwwsgosephcounVindi com /sjchp /mdex.html <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONRINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received / ?Y-" 20!/ Application Number °Za!! - 6j,01 <br />Past Reviews DIES (Date of Last Review) <br />NO <br />Staff Approval authorized by: �� 1 Title: AtitGzzi <br />Historic Commission Review Date: <br />21rocal Landmark ❑ Local Historic District (Name) <br />National Landmark Ej National Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied F� Tabled ❑ Sent To Committee [B pproved and Issued <br />DATE <br />Address of Property for proposed work: /,? 9 7 Cc' u e r 4 JS E <br />Street Number and Street Name <br />Name of Property Owner(s) (Please Print) _01C7 Z,' Al T ✓ <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: r ,, <br />(SingleFamil — Multi- Family — Commercial— Government — Industrial— vacant —etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: XIn -kind Landscape ❑ New ❑ Replacement (not in -kind) Demolition <br />(more than one box may be checked) <br />Descripti n of Proposed Work: - s•.- b � <br />Owner /Contractor: Fax: e-mail <br />(This Ul m with oMignee) and /or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />