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If <br />HISTORIC PRESERVATION COMMISSION <br />OF SOUTH BEND AND ST. JOSEPH COUNTY <br />County—City Building, South Bend, IN 46601 <br />http: //www. southbendin. gov/government/department/community-investment <br />Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@southbendin.gov <br />Ree 1Va t92q y1, ��oa <br />Timothy S. Kluse2inski, President A Ceitified Local Government of the National Paik Semite Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLP>»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 00% irk ZZ t Zdt a Application Number: <br />PastReyviemvs: ❑ YES (Date of LastReviety) <br />Staff Approval authorized by: <br />Historic Preservation Commission Revicw Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate Of App ro riateness: <br />I__I Denied ❑ Tabled <br />Address of Property for proposed work: ( Z <br />Title: <br />❑ Local Historic District (Name) _ <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />1 <br />IN <br />Name of Property Owner(s): PEt"6R B/ly 6R + 04ILY FA� �} ��, b�)�GN. Phone #: 5 7� 2 � c� ' (�8 <br />Address of Property Owner(s): Ch1 <br />(Street Number—StreetName—City--Zip) 574, ZUq •.3D°1% <br />Name ofContractor(s): I`Vt1`wd �t Phone#: *V*0 <br />Contractor Company Name: M (110.` woo COOST XJ&T/oN <br />Address of Contractor Company: <br />Current Use of Building: S ING6 a FN•M t `e <br />(Single Family --Multi Family--Commercial—Government Indushzal—Vacant—etc) <br />Type of Building Construction: <br />Proposed Work: Oln-Kind ❑ Landscape ❑ New ❑ Replacement (not in. -kind) ❑ Demolition <br />(nmore than one box may be checked) <br />Description of Proposed Rork: <br />• <br />• <br />Owner e-mail: D6+er baueXR Caws GASk.wtand/or Contractor e-mail: <br />x G1J– —� and/or x , <br />Signature of Owner Signature of Contractor <br />By signing this application I agree to abide by all local regulations related to project and to obtain a Building Department Permit; ifapplicabir. <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />