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0 <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/govemment/department/community-investment <br />Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@soutllbendin.gov <br />A Ce►tified Local Government of the National Palk Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLY» -DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 7 Z Z Die Application Number: <br />poi$ — (372S <br />YE <br />Past Reviews: S (Date of Last Review) El NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />�r <br />❑ Local Landmark Ef Local Historic District (Name) P LJ91P(N r - <br />❑ National Landmark National Register District (Name) S Dui !w <br />Certificate Of Appropriateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: <br />(Street <br />%Number Slre ame—City—Zip) 0 <br />Name of Property Owner(s): r C Phone #: �6 7 <br />Address of Property Owner(s): <br />2 ' �-r c -e - <br />(Street umber= -Street Name—City--Zip) <br />Name of Contractor(s): Phone #: <br />z <br />Contractor Company Name: ;2h:1 <br />Address of Contractor Company: <br />(Street umber—Street Name—City—Zip) <br />Cu>r•rent Use of Building: <br />Type of Building Construction: <br />Proposed Work: (more than one <br />box may be checked) <br />Description of Proposed Work: <br />• Owner <br />X <br />❑ Landscape <br />L tP <br />❑ New ❑ Replacement (not in-kind) U Demolition <br />and/or Contractorailand/or X <br />Signa r <br />By signing tivs application I agree to abide by all local regulations related to project and to obtain a Building Department Permit, if applicable. <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />