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Application <br />- FOR - <br />Cern 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 -City Building, South Bend, Indiana 46601 <br />Phone~ 574-235-9798 • Fax 574-235-M • Email: SBSjCHPC®oo.st joseph.inus <br />Website http://www.stpsephcbm"bdiamcom/qdy/mdex.html <br />OFFICE USE ONLY >>>>>> DO NOT COMPLETE ANY ENMESCONADAD EV 77115 BOX »»» OFFICE USE ONLY <br />Date Received / dW- .20 Application Number <br />Past Reviews: R WS Ot teof wmeww) <br />Staff Approval authorized by - <br />NO <br />Title: <br />Historic Commission Review Date:- <br />ElLocal Landmark © Local Historic District pvame) Y,�. �In • x' <br />National Landmark ❑ National Register District pvame) <br />Certificate of Appropriateness: <br />E] Denied E] Tabled E] Sent To Committee ❑ Approved and Issued <br />• DAiB � <br />Address of Property for proposed work: 110 W, %h/. <br />Stnet Number and Street Name <br />Name of Property Owner( s): (Please Print) �9 IC -7W,19- '9 -Y-D <br />Address of Property Owner(s): SEc f� /3o Y <br />Contractor(s) Name:�dC <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: ���✓ SGC'`} `' �% <br />(Single Family —Multi -Family — Commidal —Government — Industrial— Vacant —etc ) <br />Type of Building Construction: G00 0.00.0 <br />(Wood Frame - Brick- Stone - Steel- Conaete - Other) <br />Proposed Work: ❑ In-kind ❑ Landscape �eW Replacement (not in-kind) e Demolition <br />(mon than me box may be dw* d) <br />Desai tion of Pro osed Works 5' <br />P <br />p <br />G d �,-7-�i.�.i,5 %.yE nh-G Go ,er3i95ej <br />UJY RC2 T.�A� 2 ?�/� aY�J �O/ Cri�GG- .C3 <br />C-0 /K.51 `r>-7' {ti � T„�1 T..4c -7-2--e-.51 6-r1 koro — SE <br />Owner/Contractor. Fax e-mail � _ <br />(This of W respond with only one desii +, <br />• LUREWN S ARE LISTED ON REVERSE SIDE — <br />