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• w ; �I E a <br />\PEACE <br />x x <br />a65 <br />• <br />HISTORIC PRESERVATION COM USSION <br />OF SOUTH BEND AND ST. JOSEPH COUNTY <br />County --City Building, South Bend, IN 46601 <br />http://www.southbendirLgov/govemmenttdeparbuent/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 Park Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLri»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«<<<<0FFICE USE ONLY <br />Date Received: �� Application Number: 2-m S — O3 q <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />EglLocal Landmark <br />❑ <br />❑ National Landmark <br />❑ <br />Local Historic District (Name) <br />National Register District (Name) <br />Title: <br />Certificate Of Appro rzateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: <br />-Sato& <br />(Street Number— Street Name—City—Zip) <br />3V <br />Name of Property Owner(s): V iSSL . Phone #: 5-7 Y.77L, t O5 r <br />Address of Property Owner(s): v2 $t; �% f-/ L b Cr (-p W1^4-2 i!Li 7c.4 hir D11.7— <br />(Street Number—,Street Name—City—Zip) <br />Name of Contractor(s): <br />Contractor Company Name: <br />Address of Contractor Company: <br />Current Use of Building: <br />Phone #: <br />(Street Number—Street Name—City--Zip) <br />(Single Family—MultiFamily—Commercial--Government Industrial—Vacant—etc.) <br />Type of Building Construction: 6141 ck' <br />(Wood Frame Bricker'tone—Steel—Concrete—Other) <br />Proposed Work: MaMa-KindElLandscape New?) � Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) 1 <br />Description of Proposed Work: <br />JAIIA1 YKI LL. , <br />*Ownere-maff: l " �� �� , n r Contractor e-mail: <br />X and/or X <br />Signature of Owner Signature of Contractor <br />