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Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St County <br />Joseph Coun <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />MMjlnev Address Building, <br />South Bend, Indiana 46301 <br />Phone: 574235-9M - Fax 574235-%M I Email: SWjCffPC@wst-josephutus <br />Website htV://www.sowphCDunWdkmCDM/*hp/ilidexhbnl <br />OFFICE USE OAT <br />M>>Q0 NOT COMPLETE ANY ENTRIES CONTAINED IN 71116 BOX >>>— OFFICE USE ONLY <br />It - -%- tk - (2) <br />Date Receiv 1 1% Application Numberlic — I L <br />Past Reviews: n YES (Dote qfiatRevim) ❑ NO <br />Staff Approval authorized by.• Title: T-1-TL)AV,'(2CA-6V <br />Historic Commission Review Date: <br />ElLocal Landmark Local Historic District (Name) <br />National Landmark National Register District ovame) <br />Certificate of Appropriateness: <br />n Denied f -I Tabled Sent To Committee F1 Ippronve9dand Issued <br />DATE <br />Address of Property for proposed work- <br />-Stmt Number and Street IYaine <br />Name of Property Owner(s): (Please print) V t -I c-- <br />—U Address of Property Owner(S') 'RAJ PAI Ar K <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City-, S,- �f4 Phone: <br />Current Use of Building: <br />(single Family Mulkamily - Commercial - G"ernmen f - Industrial - Vacant - etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - stone - Steel - Concrete - Other) <br />0"� <br />Proposed Work: aKn-kind n Landscape E] New replacement (not do -kind) n Demolition <br />(more than one box may be d=W) <br />Descriptj;.of Proposed <br />o- uzri ?-5 <br />I <br />A <br />Owner/Contractor. Fax: e-mail S Pr 1* A-Q,111PA-1 e-4 t-.-. <br />(7ws!--�Z�'M:-Wdvvith oni designee) <br />j <br />and/or <br />PLICATIO <br />REQUIREMENTS ARE LISTED ONREVERSE SIDE — <br />