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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: Sl3SjCHI`C@co.st-joseph.in.us <br />Website: http://www.sgosephcountyindiana.com/s chp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received Application Number ! 0 - eo ?Z( <br />Past Reviews: E✓'YES (Date of Last Review) /0�2Q �%f '10 / / NO <br />Staff Approval authorized by: (�JCX • Q Title: <br />Historic Commission Review Date: cc�� <br />Local Landmarkcal Historic District (Name) /I� - <br />tr <br />National Landmark F] National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied [:] Tabled n Sent To Committee [proved and Issued <br />GATE <br />Address of Property for proposed work: 10T3 11% 51 q1_—r <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) %'lnt CI- Hili t_ A- • t t 6 $�S <br />Address of Property Owner(s): 10't3 R t U `'�'�C S>'24 <br />Contractor(s) Name: b I Xo11 (l \16tS <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: <br />(Single Family - Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: L -X)°9 <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work:1Y1 In-kind [-]Landscape [] New F-1Replacement(not in-kind) E] Demolition <br />(more than one box may be checked) o` ,,q� <br />Description of Proposed Work: SG G T� C.J�e'� � �h � - rSI C/� (C� <br />AA49 f7Pin!(r OrX' �At t;1L�z��Tz�;a� �:Vn;77or.1� <br />sill <br />ontractor: Fax: a -mail correspond with only one designee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />