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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: SBSJCF1PCCco.st joseph.inus <br />Website: http://www.sgosephcountyindiana.com/s chp/index.htnd <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received 2- R- 0- Application Number 2 Q I IL 02- 1 <br />Past Reviews: F1 YES (Date of Iaet Review) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />Local Landmark <br />National Landmark <br />Certificate of Appropriateness: <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />MEM <br />Title: <br />E] Denied E] Tabled n Sent To Committee E] Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />__8Vs <br />Street Ni jj,,nber and Street Name <br />Name of Property Owner(s): (Please Print) :.iAa i kt. A LAt zom&z. _5 -CIA 160th Z6/'6E0_ <br />Address of Property Owner(s): "—b2 W. VJM�A1N610NJ _ 5Wx henflr. 96160.) <br />Contractor(s) Name: i*401*4E- �IOISJn CAC it40de. QVVA Se1i GCILneCJ" <br />Contract Company Name: N I A <br />Contractor Address: t -J ) A <br />City: IJ) JA Phone: ___,57 A - Z32- 4 _ <br />Current Use of Building: - G <br />/+ (Single Family — Multi-Farnily — Commercial — Government — Industrial — Vacant — etc.) <br />C1Q <br />Type of Building Construction: QT t'p. I f bONJO <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: ❑ In-kind ❑ Landscape [:] New E] Replacement (not in-kind) emolition <br />(more than one box may be checked) <br />Description of Proposed Work: EukalL 5t-610 54Umpc QkoAn £wfb�_ <br />'?CC0,26 ( lim t f owt chr.�CNUC C -%%c:e alar i Rc e2�'C l;ne� �s��tll d�� -� 9,�►1ss. <br />Renes f10ti�Con���bt5�'tng winczjs WJ8 i,� mrr;q�e harA &e_ aoanincjs and hssca. d <br />It# bower sdn�. 'IA*1l �ntbh -*We- m cqe i'm<. as ler►,p~V ccrlee. ?i A <br />A • Q _ : <br />Owner/Contractor: Fax:574 232 -SA �l e-mail i Z���e� 1 N diAnAlcinofm <br />(This office will correspond with only one designee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — See aklx,h� <br />