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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 Soukh Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax: 574-235-9578 • Email: SBSJCHPC@co.st-josephin.us <br />Website: http://www.sqosephcounqindiana.com/sjchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONIHINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received_y_d', d -ell Application Number *1 G� l/ _ L% epe V'4 <br />V <br />Past Reviews: [fES (Date of first Review) /�c//tl//t �?DC� [� NO �r <br />Staff Approval authorized by: (Su/ Title: Azez_l i <br />Historic Commission Review Date: <br />Local Landmark eLoeal Historic District (Name) ( a <br />[� National Landmark R National Register District (Name) <br />Certificate of Appropriateness: <br />[� Denied r-1 Tabled ❑ Sent To Committee Q Approved and Issued ?,�g aoll <br />t, DATE <br />Address of Property for proposed work: �7 Z� �y �'tB ��• , 5otct l Fe,4 <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) t 7 �8 vt CIA MtE r c;r , 'V l e b, v - <br />Address of Property Owner(s): S&L- ee <br />Contractor(s) Name: �M} &'r1��%t MI 1ef' <br />/ '! <br />Contract Company Name: 1 fI vin d P-0 b -f 1101 <br />Contractor Address: 1176 k/ 000 9 7 <br />City: M1 �o,1cl' Z M _ Phone: <br />�-fa <br />Current Use of Building: n j1s - a Wt t �l1 <br />(Single Family — Multi -Family — Conmterciai — Government — Industrial — Vacant — etc,) <br />Type of Building Construction: V 't e k <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: In-kind R Landscape R New R Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) / ! 0 <br />Description of Proposed Work: �G' PIA -e4 r(1 o i,fin a, r% <br />cr�e CAFJ /t441w.e i�laJrw��iJ Ccrc�+tte�t�.►-G...t ��` gees w�rf� <br />Owner/Contractor: Fax: e-mail A telowr G)'Skl (o 1�(,t�I. ne(This officceeX91 correspond with onlyyjoonn�e designee) <br />XGj"''� _ � A `--- and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE -SIDE — <br />