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E, <br />"?, iej29`iI <br />(Z Cc D, <br />HISTORIC PRESERVATION COMMISSION 'JUN <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 />Timothy S. Klusczinsld, President A Certified Local Government of the National Parc Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE <br />Date Received: (4, 1 -7' Z 0 f <br />Application Number: 2 t:' ( 1 <br />Past Reviews: L_1 YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate Of Appropriateness: <br />11 Denied ❑ Tabled <br />❑ Local Historic District (Name) — <br />❑ National Register District (Name) <br />'HIS BOX«««OFFICE USE ONLY <br />C3(o U 7 <br />❑ NO <br />Title: <br />❑ Sent To Committee ❑ Approved and issued: <br />•Address of Property for proposed work: <br />(Street Number—Street Name—City—Zip) <br />Name of Property Owner(s): e<011"r e�id�Ll /�itiC�Ert2�ar� Phone #: <br />Address of Property Owner(s):3� �1 ✓�"/L�1� �f` <br />" �/ (Street Number—Street Name—City—Zip) <br />Name of Contractor(s): 4W Al a iii✓ Phone #: <br />Contractor Company Name: <br />Address of Contractor Company: <br />(Street Number --Street Name--City—Zip) <br />• <br />Current Use of Building: <br />(Single Family—Matlti-Family—Comniercial—Government—Indzrstr•ial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Fi-ame Brick—Stone--Steel—Concrete—Other) <br />Proposed Work: (more than one ❑ Landscape ® New © Replacement (not in-kind) Demolition <br />box may be checked) <br />Description of Proposed Work: <br />Ownere-mail: -r/_ 6bL-9 e e) L e & and/or Contractor e-mail: <br />X <br />Signature of wne <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 />