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Application <br />- FOR - <br />Certi ficate o f 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 • Emat7: SWCHPCQco st joseph in.us <br />Website: hV://wwwsgosephcoungindiana.com/gchp/index.hbnl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received% x�c.tcZO Application Number <br />Past Reviews:ES (Date ofWtReview) NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark I Local Historic District (Name) <br />National Landmark ❑ National Register District (Name) U <br />Certificate of Appropriateness: <br />Denied E] Tabled ❑ Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: 12 -lb (i W�1 5&AQ ' ,l <br />✓ // Street Number and Street Name <br />Name of Property Owner(s): (Please PP in.,t) MA` I _ /s�/ <br />Address of Property Owner(s): �7i/1 me <br />Contractor(s) Name: ! f M1 11,ov _ <br />Contract Company Name: <br />Contractor Address: <br />City.—Mil <br />�I Phone: 77 �piJ - (Yl(Z d <br />Current Use of Building: <br />(Sin5e Family — Multi -Family — Commercial — Government.— Industrial — Vacant - etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick — Stone — Steel — Concrete - Other) <br />Proposed Work: E] In-kind F] Landscape E] NewReplacement (not in-kind) E] Demolition <br />(more than one box may be dtecked) n - 0 <br />Description of Proposed Work: <br />w <br />Owner/Contractor- Fax: e-mail <br />rba arj^j a m3 vi coo <br />W uss office IunTl correspond wrt�h only one designee) <br />and/or 7/ <br />owe :a- <br />/ CC <br />— +r_F.LWT70N REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />LAL) <br />-7p <br />