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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: SBSJCHPC@co st joseph.in.us <br />Website: www.sqosephcountyindiana.com/spp/index.htn-d <br />A Certified Local Government <br />OFFICE USE ONLY »»» DQ NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» 1O_FFICE USE ONLY <br />Date Received 9 k Z 113 Application Number Z A 11- <br />Past Reviews: ❑ YES (Date of imt Review) ❑ NO j <br />Staff Approval authorized by: Q Title: Gt4 <br />Historic Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) r I n <br />❑ National Landmark [National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee [Approved and Issued G19 <br />DATE <br />Address of Property for proposed work: XUVC ,i U <br />Street Num be ad , reet Name <br />Name of Property Owner(s): (Please Print) i <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: <br />ContractQr Address: <br />� <br />City: ( ` 44'9� 47 Phone: <br />Current Use of Buildi %// I L <br />(S(nR� amily—MultWqmily—Q4,;r real — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: I A-, -Ilr, <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: ❑ In-kind ❑ Landscape ❑ New <br />(mon than one box may be checked) <br />Description of Proposed Work: <br />and/or <br />of owner. <br />(not in-kind) ❑ Demolition <br />Signature of Contractor <br />APPLICATION REQ1HREMENTS ARE LISTED ON REVERSE SIDE — <br />