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MAY 3 0 2,01-8 M A <br />8EC -No. /q M5 <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/government/department/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 Pmt 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 8c0X<—<<<OFFICE USE ONLY <br />Date Received: /I 'A Application Number: <br />Past Reviews: YES (Date of Last Review) 01 r t � Q ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: e] U n e- Z 0 \ S ,, ` — <br />El Landmark Local Historic District (Name) IVbr - r 1 O Seto <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate Of App riateness: <br />f Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: 6iZ t4, '&i <br />Name of Property Owner(s): DQM Phone 4: 57/—Q7 4/— q 7 d q <br />Address of Property Owner(s): 414,6 C) I <br />(Streebel=Street Name—City—Zip) <br />1� at ehaa 1 <br />9 Name of Contractor(s): Phone #: <br />A <br />Contractor Company Name: <br />Address of Contractor Co <br />Current Use of Building: <br />Type of Building Construe <br />Proposed Work: ❑ In -Kind ❑ Landscape PS,:1 New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) / <br />Description of Proposed Work: <br />n <br />�J <br />Owner a -mail: � rnq[a t+\ and/or Contractor a -Ina ('t✓I (c? tyt '-eF --'o <br />M <br />X and/or X r <br />Signature of Owner Si ature 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 />