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4SOUTHB� Application <br />o - ' -FOR- <br />Certificate of Appropriateness <br />\F.AC6/ <br />`+max a HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj osephcountyindiana.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 CONTAINEDINTHIS,BOX«««OFFICE USE ONLY <br />Date Received:. �3 -7)3 `2645 <br />Past Reviews: ❑ YES (Date ofLasrReview) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ DeniedElTabled <br />Application Number: (5 — 030130 <br />❑ NO <br />Title: <br />!'lv o2D/S <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />1 <br />(Please Print) j ��+ j 1/�CUf-� fr✓�L� � S /,Z IN �j <br />