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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: SBSJCHPCQcost josephin.us <br />Website: http://www.st osephcountyindiana.com/s chp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTUNED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received Application Number 2 - 6 5.3 ) <br />Past Reviews: C1 YES (Date ofz t review) 0J. /'y0Q# 201 f NO <br />Staff Approval authorized by: (,,U /� ' Title:L�f� <br />Historic Commission Review Date: <br />❑ Local Landmark cal. Historic District (Name) <br />National LandmarkNational Register District (Name) <br />Certificate of Appropriateness: <br />Denied E] Tabled ❑ Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work: / ��r7 TLfe AVE. S0. c Ili 6 / i0 <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) �i4/per KGj-C 0 -IL <br />Address of Property Owner(s): 15112 <br />Contractor(s) Name: G(CCy )4ig"4V_Z i "' <br />Contract Company Name: <br />Contractor Address: � `i�lGS a'0 <br />/.��, ls✓- '1��/5� <br />City: -VJ . �� '�1Q4 /�f Phone: 67h/` o?99_%9V9-r1 <br />Current Use of Building: '"I !� <br />(Sin Family — Multi -Family — Commercial — Government — Industrial — Vacant - etc.) <br />Type of Building Construction: Ajagae �ZA?w <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: VIn-kind F� Landscape ❑ New ❑ Replacement (not in-kind) Demolition <br />(more tl= one box may be checked) <br />Description Pro o ed Work: AeXAi /9iL /QP k� <br />be -✓e1 ia..A to/ P. gelgzrr. <br />its <br />r)eeale -k) "-'G'4 Aa rza_ i24x'14 <br />v►�PF Cc,ct rkV grids-&e_+PrG, le*t:�1 <br />wner/ o tra or: ax: _ -7 -7 e-mail <br />(This office unil correspond with only one designee °� xl�ic GE52tiL�C�� , <br />and/or C �'� 0/L <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />