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• <br />• <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/govei-nment/departmeiit/community-investment <br />Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@southbendin.gov <br />Timothy S. Klusczinski, President A Certified Local Government of the National Park Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A - CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLYS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />1 Date Received: <br />Application Number: - <br />Past Reviews: ❑ YES (Date of Last Repieip) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />ICertificate Of Appropriateness: <br />El Denied <br />Title: <br />❑ Local Historic District (Name) _ <br />❑ National Register District (Name) <br />❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: <br />V4etside <br />OW] + <br />(Sty <br />-mbei—Street Name—City—Zip) <br />Name of Property Owner(s): �t 7� S50 t 1 4� k? Phone #: <br />Address of Property Owner(s): <br />(Street Number—Street Name—City—Zip) <br />Name of Contractor(s): Trg T) Phone #: <br />Contractor Company Name: <br />Address of Contractor Company: <br />Current Use of Building: <br />(Street Number ---Street Name—Cit}--Zip) <br />(Single Family—Mitlli-Family—Commercial—Government Industrial—Vacant—eta) <br />Type of Building Construction: <br />(Wood F)•ame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: (more than one ❑ Landscape 5New ❑ Replacement (not in-kind) ❑ Demolition <br />box may be checked) <br />Owner e-mail: and/or Contractor e-mail: <br />X <br />Signature of Owner <br />and/or X <br />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, if applicable. <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />