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Application <br />-FOR- <br />Certifacate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND do ST. JOSEPH COUNTY <br />125 S. Lafayette Bivd.1 South Bend, IN 46601 <br />http://www.st oscphcountyindiana.com/dcpartments/SJCHP/index.htm - <br />p: 574-235-9798 f: 574-235-9578 e; SBSJCBPC@co.st-josep1.in.us <br />OFFICE USE ONLY -- f ONTAINFA IN TffiS HOX«c«cO�FF�I/CE USE ONLY <br />Date Received: Appitcatioa Namber. 01V /oZ <br />Past Reviews: ❑ YES (Dime e)'Drasedny <br />Staff Approval authorized by: <br />Historic Preservadon Commission Review Date: <br />❑ NO <br />Title: <br />❑ Local Landmark ❑ Local Historic District (,Yore) <br />❑ National Landmark ❑ National Register District (Nme) <br />Certificate of Appriateness: <br />rM Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) 'S_ � �• `� <br />Address of Property for proposed work: <br />(Street Number— Street Na tizip <br />cCode) p. <br />Name of PropertyOwner(s): •R�b •7G64 -- Phone#: <br />rr <br />Address of Property Owner(s): i 0- wma-,M r <br />(Street Number— Street NaCode) <br />Name of Contractor(s): G' � tin, Phone #: <br />Contract Company Name: Sub r OA� <br />Address of Contract Company: <br />(StreetNumber— Street Name—City—Zip Cade) <br />Current Use of Bpilding: LC • <br />(Single Family—Multi-Farni mmercia vernment = Industrial—Vacant--etc.) <br />Type of Building Construction: • � `f . °I <br />(Wood Frame—Brick—Stone—Steel--Concrete—Other) <br />Proposed Work: ❑ In*1nd /Landscape ❑ New ❑ Replacement (nut in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: Off 61A�. <br />ag= fic--up , wwj=�-- <br />Mi& <br />Owner/Contractor Fax #: e-mail: <br />(SYa ff will correspond with only one designee) <br />X - and/or X <br />Signature of Own& Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SMF— <br />