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Application <br />- FOR - <br />Certi f 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: SBSJCHPC@co.st josephinus <br />Website: hV:// wwwstjosephcountymdm &com /sjchp /mdexltrnl <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received o? yY�eh-G�4611 Application Number / / _ O 3.0 2 <br />Past Reviews: Q'YES (Date of Wt Review) 7 20L ❑ NO <br />Staff Approval authorized by. (i Title: <br />Historic Commission Review Date: <br />❑ Local Landmark Eg Local Historic District (Name) Gd <br />O <br />National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee [Approved and Issued <br />DATE <br />Address of Property for proposed work: ��9 elf W A /t / D r <br />Street Number and Street Name <br />Name of Property Owner(s) (Please Print) L a.0 /'P- C QS' <br />Address of Property Owner(s): LC/ g / l J r r r.✓ a �e 1) r <br />Contractor(s) Name: 9r P ,4 /-"iA. r(iy <br />Contract Company Name: Rol <br />Contractor Address: -// ( #f ,414 Pew P. <br />City: Iii OS C t �1( l� ��i�� Phone: <br />Current Use of Building S /1 r A <br />(Single Family — Multi- Family — Commercial — Government —Industrial — Vacant —etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: In -kind ❑ Landscape ❑ New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked) i . <br />Description of Proposed Work: 0-, h1 Odd s�i - 'h�,rl <br />/7 ttd <br />Owner /Contractor: Fax: 'FJ " fl' q_3 7 �6 e -mail <br />(T1us�pond urith only designee) <br />and /or <br />— APPLICATION REQ UIREMEWS ARE LISTED ON REVERSE SIDE — <br />