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• <br />A A <br />HISTORIC PRESERVATION COMMISSION �ec_'N'b. <br />OF SOUTH BEND AND ST. JOSEPH COUNTY <br />County—City Building, South Bend, IN 46601 <br />http://www.southbendin.gov/govemment/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 Pack Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE NLYS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY - <br />Date Received: (ZAI $ Application Number: 2 01 1 — 6-q 30 <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate Of App n <br />teness: <br />enied ❑ Tabled <br />❑ Local Historic District (Name) 0_624 'A i e",t C- <br />gNationai Register District (Name) Ci,� s .A Pr" la <br />❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: br,'3 Cow k A ve 5Uu+11 h, y r/ a <br />• (Street Number—Street Name—City—Zip) <br />Name of Property Owner(s): '_*trt 5 � eA ff r r t ioh Phone #: 9()9 "2 z 11 "o r 71 <br />Address of Property Owner(s): 6009 PAr k h V F -/)p4-t-4 J111 <br />(Street Number—Street Name—City—Zip) <br />Name of Contractor(s): '7oh Af 4 .4 V05 Phone #: 5-71- - `12 �_" Z ZZ I <br />Contractor Company Name:a- Y Oki ao 1/CY_;� Ot' S <br />Address of Contractor Company <br />Name—City—Zip) <br />Current Use of Building: <br />(Single Family—Mttlti-Family—Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New Ef Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />• Owner e-mail: <br />X <br />Signature of Owner <br />and/or Contractor e-mail: jO Se r fit U N n K 7 64k o4 z am <br />and/or X <br />Sign a of Contractor <br />By signing [Iris application I agree to abide by all local regulations related to project and to obtain a Building Department Pem» t, if applicable. <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />