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U <br />rA <br />Application <br />- FOR - <br />Certif icate 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: SBSJCHPC®co.st joseph.in.us <br />Website: http://www.sgosephcountyindiana.com/s chp/index.html <br />OFFICE USE ONLY >>>>>> DO NOT COMPLETE ANY ENTRIES CONRINED IlV THIS BOX >>>>> OFFICE USE ONLY <br />Date Received "1 I Application Number <br />Past Reviews: YES (Date of last Review) I NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: }�# P qui <br />Local Landmark Local Historic District (Name) <br />❑ National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: V Z C', A M GE' Ae I J C", <br />�//• n �Stt et Number and Street ame <br />Name of Property Owner(s): (Please Print) �e n n /< • /T�.•�l �(G/1 ✓/ ��i �' �� <br />Address of Property Owner(s): �?_/ /"tv E �o 74i� CA' ^ <br />Contractor(s) Name: <br />i <br />Contract Company Name: 7! W rz S <br />Contractor Address: <br />City. Phone: <br />Current Use of Building: 5-.1 1L f A- _79r2�1, M i C y <br />(Single Family - Multi -Family - Commercial - Gobernment - Industrial - Vacant - etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: Ej In-kind . E] Landscape '[New � Replacement (not in-kind) n Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: �� Ca /0 Ake Z3.6LC & <br />Owner/Contractor. Fax: e-mail <br />(This office will correspond with only one designee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />