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Application <br />FOR - <br />CerHficate of Appropriateness <br />Historic Preservation Commission of South Bend & SL Joseph County <br />12 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: Cotutty -City Building, South Bend, Indiana 4ff01 <br />Phone 574 -235 • Fax 574 - 2;x'78 • E nab: SWCHPC@wst pseplLmus <br />Website: http <br />divu.rnm /4chp /indexlhrd <br />OFFICE USE ONLY> » »> DO NOT COMPLETE ANY ENTRIES CONI7 MM IN THIS B » » >> <br />OX OFFICE USE ONLY <br />Date Received -,? 7 "YA4 °Zo // AppIication Number _ d / / - 0 7o2 7 <br />Past Reviews: Er ES (Ddeo /Last Review) [] NO <br />Staff Approval authorized by, tf� Title: <br />" Historic Commission Review Date: <br />[] Local Landmark QfOcal Historic District (Nara,) <br />[] National Landmark ❑ National Register District (Nam,) <br />Certificate of Appropriateness: <br />Denied ❑'fabled n Sent To Committee � Approved and Issued .17j44-Z611 <br />DATE <br />Address of Property for proposed work: j Y- c S t'..6 e,c <br />Street gumber and Street Name <br />Name of Property Owner(s (Please Print) <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- <br />(Single family— Multi,Famity Commercial — Government — Industrial — Vacant —etc.) <br />Type of Building Construction: <br />(Woad frame — Brick —Stone — Steel— Concrete— Other) <br />Proposed Work: In -kind ❑ Landscape ❑ New ❑ Replacement (not in - kind) Q Demolition <br />(more than one box may che*d) <br />Description of Proposed Work: <br />Owner /Contractor: Far e-mail <br />(This ojfia will 'pond k ontya� d,signu) � <br />and/or <br />-- APPUCA77ON REQUIRUEMS ARE LISTED ON REVERSE SIDE -- <br />