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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. I:afayette Blvd., South Bend, IN 46601 <br />http:/tw vw4osephcountyMana.com/departments/SJCHPrm&xhtm <br />p: 574-235-9798 f: 57 -235-9578 e: SBSJCEiP'C@ro.st jowph.in.us <br />OFF= M ONLri>>>>>po qoT comnsm ANy zmns CONTAEM IN Tgm XM<<<<<yFF=ussonr <br />Date Received: f4- 27tal/ cZ4/62 ; Application Number. <br />Past Reviews: ❑ YES. (vw*60" /�I ❑ NO <br />Staff Approval authorized by: l �� G' Tttle: <br />Historic Prouivation Commhnion Review Date: <br />❑Local Landmark ❑ Local Historic District (NwW <br />❑ National Landmark ❑ National ltegider District(Nmo <br />Certificate of Appro riateneu: <br />Denied ❑ Tabled ❑ Sent To Committee 0 Approved and bused: <br />(Please Print) /1r,, <br />Address of Property for proposed work: - -4,C,B I <br />(*edNiOnber-Street Nance-City--ZipC�))�y �} <br />Name of Property Owners): C-jrple-h (A Phone #: ' } eq <br />Address of Property Ow�ner(s): Kau h> ' <br />reet Mambo --Street Name -City -Zip Co*) <br />Name of Contractor(:): ' -rfiw <br />Contract Company Name: <br />Phone #: <br />Address of Contract Company: 7M r) <br />( (Street Number- Street Nance-City-Ztp Cade) <br />Current Use of Buildtar. <br />gie Family-Mul#Z famity-Commercial--Government-Indu blal-Vacant--etc.) <br />Type of Building Construction: <br />wood,Mop-, <br />(Wood Frame-Brick--Stares--Steel--Concrete-Other) <br />Proposed Work: ❑ In -Kind Landscape ❑ <br />New ❑Replacement (not in-kinatj ❑ Demolition <br />(mon than one box may be checked) <br />escrigtion of Proposed Work: RP-M00g, <br />A9 <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one'designee) <br />t�� <br />g Dn �? r7 t o 11 l and/or X <br />