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Application <br />- FOR - <br />Certificate i'cate o f 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 -97% • Fax 574 - 235-9578 _e Email : SBSJCEB'C ®rn.st joseph.in us <br />Website: http: / /www sgosephcountyindiana .coin/ochp /index.html <br />OFFICE USE ONLY »>>>> DO NOT COMPLETE ANY ENTRIES CON741ATED IN THIS BOX » »>> OFFICE USE ONLY <br />Date Received 3 77t4AiL OW11 Application Number <br />Past Reviews ❑ YES (Date of last Review) n V❑�jQ <br />Staff Approval authorized by. (' ` Title: Auelzb <br />Historic Commission Review Date: <br />❑ Local Landmark [t]'L•ocal Historic District (Name) <br />❑ National Landmark [B 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 A/ I A rx vc_h c <br />Street Number and Street Name <br />Name of Property Owner(s) (Please Print) " ! T / 'tc C6 <br />Address of Property Owner(s): 5(ff2- S. .7 00 t j• <br />Contractor(s) Name: Ti4S1)v1 I leda l e, e'cr - - <br />Contract Company Name: <br />Contractor Address: I f r7 �— <br />City. C9t.l'�A 20. /1 <br />Current Use of Building: <br />Type of Building Construction: <br />0 /1*v ?/ .S'f . <br />Phon : .303- 6 1 3'3 <br />( ingleFamily— Multi - Family — Commercial— Government — Industrial— Vacant —etc.) <br />(Wood From — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work kind ❑ Landscape ❑ New ❑ Replacement (not in - kind) ❑ Demolition <br />(more than one box may be checked) <br />Descriptio of Ped Work: �-� `r tom✓ a �{ 5 r� to / <br />4 c'r J d{ ro /Q� 7 h.' A.J> s6piq ICA Q ^S D2n 4roAn - ra <br />Owner /Contractor. Fax. <br />(Tian office- will comeslwnd with only one designee) <br />— APPLICATION REQU,iRBMM ARE LISTED ON REVERSE SIDE — <br />e -mail <br />and /or <br />