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r <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 • Fay 574-235-9578 • Email: SBSJCHPC@co.st-joseph.in.us <br />Website: http*//www.st osepheountyindiana.com/sjchp/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received ?xj�g 0210// hA/p�plication Number a a 1 <br />Past Reviews: M YES (Date o/ Last Review) 1,� t� x)11"1 Q NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review DaterLoTcaHistoric <br />'I <br />Local Landmark District (Name) F vpvl <br />_ <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />Denied F] Tabled E] Sent To Committee E] Approved and Issued <br />Address of Property for proposed work: • /Oj<3 11 .5 tD]✓ -�)k to <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) 141CWAE(_ A, N151_5LS <br />Address of Property Owner(s):�- <br />Contractor(s) Name: "Vc' /6 <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Phone: <br />DATE <br />Current Use of Building: <br />(Single Family — Multi -Family — Commercial — Government — industrial — Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone- Steel - Concrete - Other) <br />Proposed Work: LTJ n -kind Landscape E] New ED4eplacement (not in-kind) Demolition <br />(more than one box may be checked)] r <br />Description of Proposed Work: <br />wo u � $- Ct�A� „t Lt N (�� c_,J t •-fVr 1�1 �� 6 ` i�Q tt1 PtiC.I/ t�JooL> F'�N Cr rs Cr— <br />oat <br />C� ��u��= �x t 5 ;t.t Cs- �of�t. �rNo�..�S r� 5�<�►����2 <br />Owner/Contractor: Fax: e-mail MI CRAG( -NEC; Si�-S�S'N1,PS I(-. C -OA", <br />(This office will correspo with onll ore designee) . <br />✓�/%-� and/or <br />Signaturi of Owner - Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />