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- . ��+LQ,�i5St0+Ytgr <br />- FOR - <br />4 <br />C'eriif`ace qfA <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S, Lafayette Blvd., South Bend, iN 46501 <br />h llwww.st'ose hcotin ndiaiia.comld <br />ttP' 1 P � epartmentslSl`CHPlindex.htm <br />p: 574-235 97'98 f: 374-235-9578 . j pti.xi s <br />ei SBS7CHPC(aco.sl- ose in <br />... nw <br />OFFICE USBON r-->">rR2N0TCO'.MXjMWrwRIigC"n&jjn) TSi3 <<<<-<0F'F=VSEOATY <br />Date Received: I ` 2a A.Z.Application Number. <br />Past Reviews: YES (bateoJttRevtew) ❑..NO <br />❑ . <br />_ <br />Staff Approval authorized by: Title; <br />Historic Preservation Commission Review Date: ..... <br />❑ Local Landmark ❑ Local Historic District (mm e) <br />El <br />NatfonaI Lx�piimxrk } Nxtloasi RegLshr District (ti?snrrl <br />Certilleate of Approprixteness:. °::.:.: <br />❑ Denied ❑ Tabled ❑ SentTo Committee ❑ Approved and issued: <br />(Please Frint) ... <br />Address of Property for proposed work:- ° <br />9ftetNumberr--Street N=e,-C1ty--Z1p Code) <br />...::::..: . <br />Name of Property Owaer(s): ... ; .: Phone:". <br />Address of Property Owner(s): ii L-t..ir} <br />{Street Number --Street Nene-Clfy--Zip Code) <br />Name ofCoutractor(s): .4 -w `-)'�. =,w f .cam' -Phone#:. 7_03 7•.' 2'LIF <br />Contract Company Name: <br />t - <br />Address of Contract coin any: ' ?' =- Aj V <br />(Street NumberSheet Name -C iPe <br />-' <br />Current Use ofBullding: C� Y t tiU 11 .. ; t� ,. ....: j :1+ C''�,..� : <br />(Single gamily--11!uld- M16--Commerciat—Government.—Industrial--Vacant—em) <br />Type of Building Construction: <br />-(Wood Frame rick—Stone—Steel—Concrete--Other) <br />Proposed Work: ❑ In -Kind . ❑ Landscape [T New ❑ Replacement (not in-kind ❑ Demmolition <br />(more than one box may be check a) 1 <br />Description of Proposed Works � t ~=L,) � <br />C. Q e--(-- , moi: C_ c, <br />C umer/Contractor Fax dl: e2 -!!7e <br />(Staffs ill eorrespo d livith only one designee) _ CL <br />X andlor <br />Signature of Owner -� uci Signature of Contract ro <br />APPLICATION <br />REQUIREMENTS ARE LISTED ON REVERSE SIDE-- <br />