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• <br />• <br />rzec. I Cj a ()(P) TD -0, 'ZI <br />M4 <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/governmenVdepartment/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 Paris 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 <br />/tBOX«<««OFFICE USE ONLY <br />Date Received: 12N Ap Ir I Application Number: 2 <br />Past Reviews: YES (Date of Last Review) �/� ' ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation C ission Review Date: <br />r' <br />Local Landmark ❑ Local Historic District (Name) <br />❑ National Landmark National Register District (Name) r✓6yv 11!V Yl� I� i��C �1�L�uwrU <br />Certificate Of Appropriateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: <br />Name of Property Owner(s): <br />Address of Property Owner(s): <br />Name of Contractor(s): <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 />Owner e-mail: <br />X <br />Signature of Owner <br />(Street Number—Street N, <br />2 1-fyn <br />" 4 vLy <br />(Street Number—Street <br />(Street Number—Street Name—City—Zip) <br />( LfldlPft 0/ 1 —cot'''! <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />❑ Landscape P New ❑ Replacement (not in-kind) ❑ Demolition <br />zo / 'Lin; -14111 e-k�lr' - 0/ - <br />and/or Contractor e -m il: WP t n 4 Cml<uc#.-' , <br />Goy( <br />_ and/or X <br />Signatur of ontrac r <br />By signing this application I agree to abide by all local regulations related to project and to obtain a Building Department Permit, i£applicable. <br />