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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: 574-235-9578 • Email: SBSJCHPC®co.st josephinus <br />Website: http://www.sgosephcountyindiana com/gchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received��011 Application Number 1 - UP 0 It <br />Past Reviews: kjYES (Date ofWtReview)AA*_— \ 1J \ I� ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: / <br />❑ Local Landmark 56 Local Historic District (Name)�it n ��• <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: s • fN%i4'F4%#.4 h6m pry <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) K 15V I ri ?:)J (; C g4-(-- /J"T C> , 4A <br />Address of PropertyOwner(s): SOI I-, 7-W**r-40-4 DwL ,Zwni M -1D 171 4&lelS <br />Contcactor(s) Name: OW 11 f - <br />Contract Company Name: `('+/f,V- <br />Contractor Address: <br />Phone: <br />City: i'f� <br />Current Use of Building: /LY &W 1►c- ' <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: FIR-ASE- <br />(Wood <br />2-ASE -(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: IX In-kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />P SS Description of Proposed Work: I N517 iIWO'i O= -S r{ a4 -d F -P-16 6 <br />DRi - 4011", r-Atbv/7 & /_47wri !.I ir- ri;r(v,Z ._ f= cls YiiWO td J r,xrvr4 e_mo 1 Prz,.-x _ <br />rt P tj 5VV 174- (-X" FFA Of— YTPO <br />Owner/Contractor. Fax: / //}' e-mail IG l3 JC.G t-/�it��i� l-1 wAt <br />(This office will correspond udth only one�designee) <br />%01 - 1pv - lWa / Gr -u) and/or 6-14 &91 "4 111 (uS0. i-) <br />571 • 2,&7- I U 6te 04646-) <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />