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Application <br />- FOR - <br />Certificate icate 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 - EmaB: SBSJCf PC®cost josephinus <br />Website: http://wwwstjosephcountyindiana.com/sjchp/mdex.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONFINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received /5 A" Application Number _4:�-Q 1 I <br />Past Reviews: ❑ YES (Date cf last Pi.) n ❑ NO <br />Staff Approval authorized by: r "✓ Title: %t.Gtr►.f-� <br />Historic Commission Review Date: <br />❑ Local Landmark cal Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee [EJApproved and Issued l�A.44 'Zo <br />DATE <br />Address of Property for proposed work: <br />Street ty�imber and Street Name <br />Name of Property Owner(s): (Please Print) 2 CA p-0(& n�'k j <br />Address of Property Owner(s): Kn 16 2 !I t t/�P ✓J / �i z U% <br />Contractor(s) Name: / /I ✓ rn nom- '�G✓� e <br />Contract Company Name: / C - <br />Contractor Address: �-/ `%- 9 6 <►, G✓U G� �1 ° <br />City: L;j .ey'f3. SIV Phone: -- Z 2- 7 d a <br />Current Use of Building <br />(Single Family- Iti-Family-Commercial-Government -Industrial- Vacant -etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind %Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed 11.1ork: ke'44 h/`P Of t P. / % 144, <br />Owner/Conactor Fax: e-mail <br />(This office unit drmowd with only one designee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />