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Fkt!l <br />DEC <br />Ed <br />10 7012 <br />Application <br />- FOR - <br />Certificate icate o f 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:574-235-97'98 • Fax 574-235.9578 • Email: SBS)CHPC®ao.st josephinus <br />Website: http://www.sgosepheoungindiana.eom/*hp/kdex.html <br />*-11) r) (i 0� <br />a <br />OFFICE USE ONLY r»�»» DO NOT COMPLETE ANY ENTRIES CONRnVED IN THIS BOX »»» OSCE USE ONLY <br />Date Received � t < 10 , I ;), Application Number 2 - 11A\0 <br />Past Reviews: N(YES (Date a f lost miew) ' 1 . " l • ❑ NO <br />Staff Approval authorized by - <br />Historic Commission Review Date: 1 J��� a O , �(� <br />❑ SA - <br />Local Landmark gLocal Historic District (Name) <br />❑ National Landmark ❑ National Register District pvame) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />nnrta <br />Address of Property for proposed work oto <br />Street Number a d Street "e <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): .1 �� F. l A i rt Hfl ?" c)+ l l f <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: 1 " �.� �. 9� �`' i ���s-1-1�� Phone: <br />Current Use of Building: `, _ „ yr, <br />ngle Family — Multi -Family — Corrtmadal —Government — Industrial — Vacant — dt) <br />Type of Building Construction: <br />(Wood Frame — Bride — Stone — Steel — Conaete — Other) - <br />Proposed Work: ❑ In-kind ❑ Landscape E]New O Replacement-(notin- ind)_❑.Demolition____.-_-..:r-_-.___ <br />(mare than one box may be dhd ed) <br />Description of Proposed Work: <br />77 <br />jr;espond <br />Fax: J �� a -mail - - - - - - -_ - <br />thonlyonedesignee) <br />`� and/or <br />APPLICATION REQUIRE MM ARE LISTED ON REVERSE SIDE — <br />