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Application <br />-FOR - <br />CeW 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_ity Building; South Bend, Indiana 46601 <br />Phone: 574 - 7359798 • Fax 574 - 2369578 • EmaM SBSJCHPC®co.st joseph.in us <br />Website: http:// wwwatjas ephcountyindiana.00m /sjchp /index html <br />OFFICE USE ONLY»»» DO NOT COMPLETEANYE)VTRIES CONRRVED INTHIS BOX » »» OFFICE USE ONLY <br />Date Receive o2 1 O W/ Application Number A O f J - O <br />Past Reviews: BffES (Dare of t.,t W.) 02 020 / O ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: /,au¢ .W/ / C� <br />❑ Local Landmark ❑v'Cacal Historic District (Name) �T� -r-� -• <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ lkbled ❑ Sent 7b Committee ❑ Approved and Issued <br />Address of Property for proposed work: a q <br />Street Nu = ,"d Stmt Name <br />Name of Property Owner(s): (Please Print) ( G k_f ate/ 1 •.tea!' <br />Address of Property Owner(s): C 4 <br />Contractor {s) Name: q 1 rke;a '4. <br />"r•=� r!' S` � S O � v i +tom <br />Contract Company Name: go ^.P _ T.Q1 C J r C Q <br />Contractor Address: jgi ::� 6-Z / V r (7c� <br />City cnQ ✓,TT <br />Current Use of Building. <br />Type of Building Construction: <br />DATE <br />Phone: -q'7 <br />IeFamil Multi - Family- Commercial - Government- Industrial - Vacant -etc.) <br />Fram<>- Brick - Stone -Steel - Concrete - Other) <br />Proposed Work: ❑ In - kind ❑ Landscape ® New ❑ Replacement (not in4dnd) ❑ Demolition <br />(more than one box my 6r &dm / <br />Description of Proposed Work- <br />- t7 <br />Owner /Contractor: Fax: e-mail Rf <br />(This office will wmVm d with n y one designee ) <br />and /or <br />- APPLICATION REQUnU% E Vn ARE LISTED ON REVERSE SIDE — <br />