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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: S%jCHPC®co.st josephin us <br />Website: hV://www.s§oseplicountyindiana.com/sjchp/indexhtml <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES COArA[NED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received eta 066 oW -1 j Application Number PZ42_/ �— - /0 0? 09 <br />Past Reviews: L s (D„teoflast Review) F1 NO <br />StafFApproval authorized by- TI{)e: <br />Historic Commission Review Date: ' <br />[cal Landmark 0 Local Historic District (Name) <br />❑ National Landmark [] National Register District Mame) <br />Cettiflcate of Appropriateness: <br />F] Denied E] Tabled E] Sent To Committee [�'�pproved and Issued Wt? <br />DATE <br />Address of Property for proposed work: DL'3 - <br />11 1 y Street Nnn�and Strt Nar <br />Name of Property Owner(s): (Please Print) <br />ee <br />Address of Property Owner(s): oz'+ G�- <br />Contractor(s) Name: W <br />Contract Company Name: r=Ftvtil �p <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: C+ <br />(Single Fami7u - Mrdti-Family - Commercial - Governmen - Ind nstrinl - Vacant - et ) <br />Type of Building Construction: ! °tt.rtt 4 Cf+ <br />(Wood Fraine - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: E] In-kind E] Landscape 21"Rew [:] Replacement (not in-kind) E] Demolition <br />(more than one box may be checker!) _ <br />Description of Proposed Work:►- <br />C' M ®'v %-.® C ` ..sa <br />Owner/Contractor. Fax: <br />(This office Wl correspond with only/ one designee) <br />and/or <br />e-mail <br />— APPLICA770N REQLUREMENTS ARE LISTED ON REVERSE SIDE - <br />