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• <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/government/department/community-investment <br />Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@southbendin.gov <br />Timothy S. Klusezinski, 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 ONLY>»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: q1Z to Zd f Application Number: 261S __0 cl Z (A C <br />Past Reviews: ❑ YES (Date of LastRevierv) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Local Landmark <br />❑ National Landmark <br />Certificate Of Appropriateness: <br />El Denied ❑ Tabled <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />Address of Property for proposed work: (,36 <br />Title: <br />❑ Sent To Committee ❑ Approved and issued: <br />1) <br />` (Street Number—Str et Name—City—Zip) s <br />Name of Property Owner(s): tAAAAELS Ji- � 1 N Phone #: <br />Address of Property Owner(s): <br />Name of Contractor(s): <br />'-71-12 1 Phone #: <br />Contractor Company Name: <br />Address of Contractor Company: <br />jj (Street Number—Street Name—City—Zip) <br />Current Use of Building: a }'tG �6'�' aa�� L1 K1 <br />(Single <br />�Family Fr_ <br />ulti-Family—Commercial—Government I .) <br />ndustrial—Yacant—etc <br />W <br />Type of Building Construction: LR d T ` q .,vi q <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ISIn=Kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />•Ow er a -mail• i �� 1 ►"'arid%or Contractor e-mail: <br />X and/or X <br />SI ure of Owner Signature of Contractor <br />By signing this application 1 agree to abide by all local regulations related to project turd to obtain a Building Department Permit, if applicable. <br />