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Application <br />- FOR - <br />CerHficate 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: 574235 -9798 Fax 574235%578 • . Eva A- SBSJCHPC ®cost josephinus . <br />Website: http: / /www.stjosephcounVmdm &corn /sjchp /mdex htn l <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANYENTRIES CONTjngED IN THIS BOX » »» O FFICE USE ONLY <br />Date Received Application Application Number �/— - 4 711 <br />Past Reviews: ES (Date oftAst Raier•) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: ' •�(f i // <br />Local Landmark cal Historic District (Name)��� <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />(] Denied Tabled ❑ Sent To Committee E] Approved and Issued <br />Address of Property for proposed work: ("Z <br />St <br />reelSVumber and Street Name <br />Name of Property Owner(s): (please print) I� / a t ree <br />Address of Property Owner(s): t / 5 - 92 - 5. _ 300 <br />Contractor(s) Name: .xav <br />Contract Company Name: <br />Contractor Address: al ;'O-e-4 �-f <br />City: �� _ / 4/ <br />Current Use of Building:' <br />'type of Building Construction: <br />Phone: ,S7f/ �O.3 °� 13 3 <br />mgleFami Multi- Family — Commercial— Government— Industrial— Vacant —etc.) <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: R In -kind <br />(more than one box may be ehedW) <br />r <br />Description of Proposed Work: - <br />Owner /Contractor. Faic <br />(This office u x aornespon with only am designee) <br />❑ Landscape ❑ New ❑ Replacement (not in -kind) [] Demolii <br />_ D v <br />��it1 il,�fKrLG2 cx LW% � ,R,L2s� <br />e -mail <br />and /or <br />- APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />