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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/goveimmcnt/departinent/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 Pads Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLY»»Q»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS <br />BOX`—«—OFFICE USE ONLY <br />Date Received: -/Cl Application Number: <br />Past Reviews: L=! YES (Date of Last Review) LP1 -7 d NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: ` : j, } <br />❑ Local Landmark E/ Local Historic District (Nance) Vie W Di� S ik 70 <br />❑ National Landmark ❑ National Register District (Nance) <br />Certificate Of App n <br />teness: <br />enied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: 90/ IN IVBr tShot✓ W 1 VG <br />(Street Number—Street Name—City—Zip) <br />Name of Property Owner(s): t IW~ .t. J 040ne- Phone #: <br />Address of Property Owner(s): a0/ 4' <br />(Street Number—Street <br />• <br />• <br />Name of Contractor(s): 15de 94"1414— Ply -k l f A. Phone #: Sec. <br />Contractor Company Name: <br />Address of Contractor Company: <br />Current Use of Building: <br />Type of Building Construction: <br />Proposed Work: ❑ In -Kind <br />(more than one box may be checked) <br />Description of Proposed Work: <br />(Street Number—Street Name-City—Zip) <br />lc- FcaK+t/y Horne. pltcf Cetr'rtage house anartlmea Creer<t' <br />Crani e <br />(Wood Frame—Brick—Stone—Steel—Concrete Other) <br />❑ Landscape ❑ New <br />WAE <br />❑ Replacement (not in-kind) ❑ Demolition <br />Piyll►.lp9 px_a <br />c o rer r acct r Y a S <br />a i f �.- uwr t 3 e vG e <br />Frees G(lOw aeee55iYei4 A<err•ntiplan 76� il• atvlooristb� 8 '✓'6"+ir *x e4j*-, t -ala y at�n�d * u�6jts.lat-E <br />Owner a -mail: b D eti w* O wrest I. clnn and/or Contra a -mail: G'CtPN�r l ' f jir/re p0ivr�t c� <br />X� 1" T � bi-bdv�,Jo�•� 5.,urtt,c�•, <br />(� and/or X <br />(urSSIgnaturee of Owner 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 />