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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. Lafayette B11d., South Bend, IN A C CA 1 <br />hq://www.sgosephcountyindiamtom/depattments/SJM/mdex.htin <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCBPC@co.st-josej)fiin.us <br />OFFICE USE 0M «««pFFICB USE ONLY <br />Date Received: oe 7' /"-Y Application Number: c-/©/-7— <br />Past Reviews: YES (Dare of Lott Review) E] NO ����jj <br />Staff Approval authorized by: Title: i(l axez l <br />Historic Preservation Commission Review Date: .� <br />Local Landmark Local Historic District (Name)'' <br />National Landmark National Register District (Nam,) <br />Certificate of App riateness: <br />T1 Denied Tabled Q Sent To Committee ® Approved and Issued: <br />(Please Print) <br />Address of Property for proposed work: 1.fV�,�' <br />(Scree umbelSL Street on City—rp <br />Name of Property Owners) 11 r ,.4, i' /� �/i>d C `; Phone #: <br />Address of Property Owner(s): I -.e <br />(Street Number— Street Name—City—Zip Code) f <br />Name of Contractor(s): ///, U. Phone *,g <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: <br />(S <br />Type of Building Construction: <br />Proposed Work: .In -Kind <br />(more than one bar may be checker!) <br />Descril <br />(Street Number— Street Name--City—Zin Code) <br />❑ Landscape ❑ New ❑ Replacement (not in-klnr ❑ Demolition <br />Owner/Contractor Fax #: 357 0937 e-mail: <br />(Staff will torress%pond with only one designee) ` <br />X and/or X <br />SI ature of weer Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />- =.e:-- ;- <br />