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t <br />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: SBSJCHPCQco.st josephinus <br />Website: h4://www.st osephcountyindiana.com/sjchp/index.hhnl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONEUNED IN THIS BOX-- OFFICE USE ONLY <br />Date Received o2 / C4 4&e- 010 // Application Number a O / - 0 5CZ / <br />Past Reviews: [✓]'YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: / !xrW Zd / / <br />❑ Local Landmark 2<ocal Historic District (Name) ' _ <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: 0� <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE / I I I <br />I <br />Address of Property for proposed work: LA Z1, ry <br />Stree Number and Street Name/� (rJ , ` /d <br />Name of Property Owner(s): (Please Print) 'I, C , A N L. A n <br />h �� 0 ja OL n (� 0 40 <br />� r v <br />Address of Property Owner(s): 8,O)g I LA LL /4 e! ti=C7 in � <br />Contractor(s) Name: _�/� I�f �� � <br />Contract Company Name: / rt h c � _4 is n_Ao Qom/ g e . i <br />Contractor Address: _.p�� /{ /2 ^ / Q ►� . / <br />City: r .��, l A rrl Phone: (.'S 7 ��,y- ;t 95 <br />Current Use of Building <br />(Single Family` Multi -Family — Commerlial— Government — Industrial — Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: FfIn-kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />)wner/Contractor: ax: e-mail <br />Th' will and with nIy ozre designee) <br />I .ice <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />