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Application <br />- FOR - <br />Certificate 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: 574235-'578 • Email: SBSjCHPC@co.st joseph.inus <br />Website: httpr//www.stjosepha)untyindhvmcom/Ichp/indexhtml <br />OFFICE USE ONLY»»» DO NOT COMPLETE ANY ENTRIES CONK VED IN THIS BOX »»» OFFICE USE ONLY" <br />Date Received 3 Xsv- -W# Application Number ° o l / - /G L43 <br />Past Reviews: [] YES (Dote of Last iteview) [] NO <br />Staff Approval authorized by: t/7i9 Title: � <br />Historic Commission Review Date: <br />(� Local Landmark [ glocal Historic District (Name) <br />[� National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />[] Denied n Tabled Sent To Committee ' [R<pproved and Issued 3 X*O' J-0 1/ <br />DATE <br />Address of Property for proposed work: ! 0 L5._r l 1 V HA 5 1 Q E �D a - <br />-�^ Street Number and Street Name <br />Name of Property Owner(s): (Please Print) SL ��A- &A -''S) <br />Address of Property Owner(s): �j!ep.a- ! . P7� AV <br />Contractor(s) Name: <br />Contract Company Name: k ;d17�►j, jt��(�*t/�' <br />Contractor Address: 0 X <br />City: �?,�- f CI Phone: <br />Current Use of Building:-----�� = <br />((Single Family)Multi-Familly— 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 awry be checked) - <br />Description of Proposed Work:�C <br />Owner/Contractor. Fax: e-mail <br />(This office wall correspond with only one designee) <br />X< and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />