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r� <br />Application <br />-FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />175 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: Couniy-City Building, South Bend, Indiana 1466Q1 <br />Phone: 574235-9798 • Fax: 574-235-9:7>8 • Ema SBSJCHPC@co.st josephin.us <br />Website: http://www.sqosephcounqbdLvacom/sjchp/index.hbnl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES COAMINED IN 77HS BOX »»» OFFICE USE ONLY <br />Date Received "I'PeGl r Application Number � ° 1 f - 4 � Y <br />Past Reviews: S (note of last gmm) <br />Me <br />Staff Approval authorized by: Title: <br />Historic C rnmissian Review Date: <br />Local Landmark 2focal Historic District (Nano) <br />Q National Landmark Q National Register District wamt) <br />Certificate of Appropriateness: <br />Q Denied [] Tabled , Q Sent To Committee Q Approved and Issued <br />DATE <br />Address of Property for proposed work: �` 7=r�:;i; 1 <br />Street"ober and Street Name <br />Name of Property Owner(s): (Pleam Print) <br />Address of Property Owner(s): --� �'�" � �' ! ,4-1� <br />Contractor(s) Name:It <br />}J''c <br />Contract Company Name:1711 <br />Contractor Address: <br />City. Phone <br />Current Use of Building: ' r I { .... /= r -1t t 51 Z'4" - it <br />(Singh Family - Multi -Family - Commercial - Government - Industrial - Vacant -etc.) <br />ljrpe of Building Construction: <br />(Wood Frame - Brick - Stone - Suet - Concrete - Other) <br />Proposed Work: Q in-kind Q Landscape Q New [Dteplacement (not in-kind) Q Demolition <br />(more bran one )rax may k cwe%i) <br />Description of Proposed Work:fi;�'r'L <br />Owner/Contractor: Fax: . <br />{This o,(Jue w`itl correspond urith onlyonk designer) ; <br />tt 9 <br />A <br />jJ <br />e-mail'7`"tIt` <br />and/or - a` <br />— APPUCA77ON REQIIIREMENTS ARE LISTED ON Ria TR5B SIDE — <br />d <br />