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- - -- -. - - <br />Via! MST, ORIC'PRESERVATION C4Ml��IISSION <br />ju OF.SOUTH BEND AND ST. JOSEPH OUNTY <br />1Gbunty� Ci{y Build(ng, SoutH--Bund,- 661 <br />http:i/www.sOtiihberi � ri.gov/gov6mmeiiVdepartment goi�nmuh ,itivestment� <br />Phone:`574/235.937i; Fax 574%2359021, <br />Email: hpcs4sje@southb640gPv <br />Timothy S KluscAnski,, President ` ' I , A Ceitified, Local Govemment of the Piational Pads Service Elicia Feasel, Historic Weservatlon - <br />r; Admimsnaio- <br />APPLICATLON FOR A — CE'RTIF`ICATE OF APPROPRIATENESS <br />OFFICE,,USE O1VLY?»»>DO N,bT�COMPLFTE ANY ENTRIES CONTAINED iN THIS,S k �ig <br />«<«zO,F'FyCE USE ONL <br />Date Received: Application Numbers1-40111 1 <br />' — 1� Q_A <br />Past Reviews: ❑ YES" (Date ofL7ist {teview) ' ❑ NO <br />r i , <br />i <br />Staff Approval_anthorized by: Title:. ` <br />I <br />Historic Preservation Commission Review Date; <br />Local Landmark Local Historic District Ndme a <br />1sJ � � it ) 1 �' I <br />- h <br />❑ t" 1 <br />❑ ational Register NationalLa ' <br />= _ _ N District ieme I <br />r <br />Certificate Of.Appro riatenesa. <br />Denied ❑Tabled Sent To Committee' Approved andrissued 1 ` <br />� <br />pro osed work•' // ,� �1 _ �� - 0 <br />Address,of Property for p p1 j l �t%L d td <br />(Street dumber--Strut Name—city —Zip; <br />Name pf Property Qwiier,(sj l� L f Ie7 l-•-� �`� ' �T Y Phone # , �S1 � , �� � � Y 6 ,! <br />r p. rtY { j l t% �i,� . <br />dress of Pro a Owners (tr e ber c <br />ee C r <br />Set Num -Sir' t Name Ci dip) <br />_ <br />Name of Contractor(s): C (`�' yPhone <br />Contractor+Companv Name: U <br />Address of Contractor` Company: t% (, ,' 11 C, <br />' Street jqum�ier� Meet Niriie�-Git�y -Zil <br />01 <br />wr <br />1q. , <br />_Current Use of Building, G <br />(Single Famiht _-Multi-Famit �4mmerc:at . Governrizeni—industriaf=`Vacant <br />Type of Building onstraction j9 C LO/A I It rn / i(,) m) `/r IN '000, <br />(Wood Frame—Brie —Stone=�Steet Concrete—Other) <br />Pro osed;Work• In Kind Landsc i e _ ❑New Re lacement not i»=kind ❑ ;Demolition <br />p- p p ( ) <br />(more than ones box mayben Tb <br />„ <br />Iles ription of Paposerl o <br />1 <br />I , <br />-Owner,emxii , C d �, I and/or <br />Contractor,e-mail• \ <br />u <br />X, andfor1,X <br />�IgnatUre Of OwerSlg'na'faie of Contractor 1. <br />I <br />p, � <br />vsmc suis apgLoanon ae`ize td pbide by all'local reeulatiops relatedq,pmjectand to obuki� a Bmidn Dep"ent PermiLjifappycabe. <br />�PPIICAT�ON REQUIREMENTS ARE LSTED ON REVERSE SIDE <br />I <br />r <br />