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South Bend and St. Joseph County <br />HISTORIC PRESERVATION COMMISSION <br />Timothy S. Klusczinski, President <br />Name <br />Address: <br />Email: <br />Date/Time of Request: <br />227 WEST JEFFERSON BLVD <br />SOUTH BEND, IN 46601-1830 <br />www.stjosephcountyindiana.com/sjchp/index.html <br />Phone: 574-235-9798 Fax: 574-235-9578 <br />e-mail: SBSJCHPC@co.st-joseph.in.us <br />A Certified Local Government <br />REQUEST FOR DISCLOSURE OF PUBLIC RECORDS <br />Phone: <br />Elicia Feasel, Executive Director <br />Please clearly identify the record being requested (be as specific as possible): <br />This is a request for: <br />Signature required: <br />(if more space is needed please use reverse side of request form) <br />permission to inspect record requested <br />you to provide me with a copy of the record at the price of $.25 per page <br />with the understanding that the copy fee must be paid before the record <br />will be distributed <br />DO NOT WRITE BELOW THIS LINE—FOR OFFICE USE ONLY <br />Date/Time of request received: <br />Name of person receiving request: <br />Disposition of request: <br />Signature: <br />COMMISSIONERS <br />Thomas Gordon (Vice President) <br />Mike Voll (Treasurer) <br />Jennifer Parker (Architectural Historian) <br />Elizabeth Hertel (Secretary) <br />Kevin Buccellato <br />Brandon Anderson <br />Michele Gelfman <br />STAFF <br />Deputy Director <br />Tony Zappia, Legal Counsel <br />Steve Szaday, Preservation Specialist <br />Date: <br />Date: <br />HISTORIC <br />PRESERVATION <br />COMMISSION <br />OF SOUTH BEND & ST. JOSEPH COUNTY <br />ESr. 1973 <br />