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Application <br />-FOR- <br />Certificate <br />OR-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: rminhy-r4tv, South Rend, T -A;,— AAAA1 <br />Phone: 574-235-9798 Far. 574-235-95778 * Email: SffijC1­l11'C4cc,.st+)scph.in.us <br />V*bsitL- http://%vi"v.s". licountyitidiam,com/sjchp/indc%.htn-d <br />OFFICE USE 04%1'LY>>>>>> DO NOT COMPLETE ANY ENTRIES CONlr4lNTD IN THIS BOY -—OFFICE USE ONLY <br />Date Received Z Application .Number - eso.ZB <br />Past Reviews:] E] NO <br />Staff Approval authorized by: Title: <br />to <br />Historic Commission Review Date:l(i <br />F1 Local Landmark Local Historic District ova",r) Di'v e <br />n National Landmark E] National Register District (Sante) <br />Certificate of Appropriateness: <br />Denied Tabled n Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />Street NUMIler and Start Ml"x <br />Name or Property Owner(s): (Please Print) <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: f��Jz <br />City: Sr'(1.r1l '060,12 Phone: 3 vv - s - <br />Current Use of Building- <br />Sis:1, �K, it .-Multi-Family- Onnwreid -Gou,rnment -IndustrW_ Vacant -etc.) <br />Type of Building Construction:—,7Z.? <br />L,e <br />(44'cvd Frame - Brick - Slott- - Steel - Ce"crete - other) <br />Proposed Work: [] In-kind n Landscape n New Replacement (not in-kind) E] Demolition <br />(mw thin one lux vyq Ir -�hecW) <br />Description of Proposed Work: -U/ Wrz- 1,W15 <br />z,��x <br />Owner/Contractor: Fax, e-mail 6b71 -? A. <br />{This <br />u0i onlY one desj(nee) <br />xand/or <br />4"L`CAT70J\T.REQUIRCX1EN7S.A RE LISTED ON REVERSE SIDE — <br />