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SCSOUZU Application �`00NOSSio"fqs <br />-FOR- <br />PEACs.. <br />�� -,, Certificate of Appropriateness <br />f� �\ E ,Ca <br />m <br />- a HISTORIC PRESERVATION COMMISSION <br />1865 x of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://mvw.stj osephcountyi ndi ana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 - f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX« <<OFFICE USE ONLY ' <br />Date Received: o,4– 2�& .204S -Application Number: 030 <br />Past Reviews: ❑ YES (Dateof/.as[eevien) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: 14 <br />Local LandmarkF]Local Historic District (Name) <br />ErNational Landmark ❑ National Register District (,vam ) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To CommitteeElApproved and issued: <br />.. „,,. - . ..,,,,,..,..,,,.,.,,,.,,... . .,.,.,..,,.,..,.......,, _...., ..,, __...,..,.._.,.— ...,.. .... <br />(Please Print) <br />Address of Property for proposed work: 820 N. Michigan Street - South Bend - IN - 46601 (Leeper Park) <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): City of South Bend Phone #: 574-235-9251 <br />Address of Property Owner(s): 227 West Jefferson Boulevard - South Bend - IN - 46601 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): To Be Determined After Bid Results Phone #• T.B.D. <br />Contract Company Name: T.B.D. <br />Address of Contract Company: T-B.D. <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: N/A <br />(Single Family—Midti-Family—Commercial—Government Industrial—Vacant—etc) <br />Type of Building Construction: N/A <br />(Mood Frame—Bi•ick—Stone—Steel—Concrete—Othei) <br />Proposed Work: ❑ In -Kind N Landscape ❑x New ❑ Replacement. (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: See Attached <br />Owner/Contr for Fax #: N/A <br />(Staff tivi col es nd th one designee) <br />X <br />Si ure of Owner <br />e-mail: pekerr@southbendin.gov <br />and/or X T.B.D. <br />Signature of Contractor <br />el <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />