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HISTORIC PRESERVATION COMMISSION <br />OF SOUTH BEND AND ST. JOSEPH COUNTY <br />\` a CE County—City Building, South Bend, IN 46601 <br />http://www.southbendin.gov/govemmenttdepartment/community-investment <br />% 1865,y Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@southbendin.gov <br />Timothy S. Klusezinski, President A Certified Local Goverument of fire National Patk Seivice Elicia Feasel,'Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFIICE USE ONLY»»»DONOT COMPLETE ANY ENTRIES CONT <br />Date Received: Application Number: _ <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark � Local Historic District (Name) <br />❑ National Landmark National Register District (Name) <br />Certificate Of Appropriateness: <br />Li Denied ❑ Tabled Dent To Committee ❑ Approved and issued: <br />IN THIS BOX«««OFFICE USE ONLY <br />❑ NO <br />Title: <br />Address of Property for proposed work: 00 L) <br />(Street NumbV—Street Name—City—Zip) <br />Name of Property Owner(s): S� • Jorma N C' ems? Phone #: <br />Address of Property Owner(s): <br />(Street Number --,Street Name—City—Zip) <br />Name of Contractor(s): TAP. Phone #: <br />Contractor Company Name: <br />Address of Contractor Company: <br />Current Use of Building: <br />(Single <br />Type of Building Construction: <br />(Street Number -Street Name—City-Zip) <br />(Wood Fi•ame Buick- Stone—Steel—Concrete—Othei) <br />Proposed Work: (more than one ❑ Landscape li I New ❑ Replacement (not in-kind) ❑ Demolition <br />box may be checked) <br />Owner e-mail: and/or Contractor e-mail: <br />x and/or X <br />Signature of Owner Signature of Contractor <br />By signing this application l 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 />• <br />• <br />• <br />