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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/departineiit/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 Parc 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: LA WY -10- Application Number: — 0 (0 O <br />Past Reviews: 2 YES (Date of Last Review) Dri ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: S. )\) n_e_ 11;? -1.1 Is <br />19"Local Landmark 191"Local Historic District (Name) � t n Cil f <br />-FINational Landmark ❑ National Register District (Name) <br />Certificate Of Appropriateness: <br />E] Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: ID l Pt Mr1+ 6&-, Se, 1,V 4461& <br />(Street Number -,Street Name -City -Zip) <br />Name of Property Owner(s): jr N i✓" N X017 OE -TI (,A/ S"r VOW t) Phone #: Y-rk ` 7/ % 3/5"7 <br />Address of Property Owner(s): s ?F tiwr d tz ` 1-0 S 14N &L &�1 CA 7402-32- <br />(Street <br />40Z3(Street Number -Street Name -City -Zip) <br />Name of Contractor(s): <br />Contractor Company Name: �% (a, G y n r rP .tit �1/ Ce iy rn 6"C ri vAl <br />Phone#: S7d-232"IZ0O <br />Address of Contractor Company: 2-3 1 T6 / 0-0 L,4 -,v0 Wil? <br />(Street Number --Street Name--City-:-Zip) <br />Current Use of Building: <br />A A/7 - <br />(Single <br />0 <br />• <br />Type of Building Construction: 1410 0 7 F72 A -Ad 6- Wt TT/ AAA,-Tv.V K- V 4 f TC& L- 8 et4g;'-r/v 6- dr L 6rp"`` -rs <br />(Wood Fiame Brick--Ston"tteel-Concrete-Other) <br />Proposed Work: R1 In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: ( tl/6- e-0 S- : L r it 7-5 -- A(O7-C / / dA! Tf 7z;- ft-� ` <br />(' R 0 P rdU CfiGLxS PDX AVG w f'orV01tr WTW & liru t � S <br />Owner e-mail: and/or Contractor <br />X and/or X <br />Signature of Owner Sig ture 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 />