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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 />A Certified Local Govemment of the National Patio Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE <br />y�ONL Yt>C»� DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />y <br />Date Received: I t / , ` t ` U Application Number: �qt — o o k <br />Past Reviews: ❑ YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate OfAppropriateness: <br />Denied ❑ Tabled <br />Title: <br />❑ Local Historic District (Name) <br />National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: :J(an fa r 4: o, e. A tl 5,)4A ,tom) I N U (a G / (� <br />(Street umber—Street Name—City—Zip) <br />Name of Property Owner(s):5C r AQL X �� S c, A , Phone #: (S�) ZZ6 � 0o S <br />r <br />Address of Property Owner(s): 1(13Co Lav -rt-- I + . E/tcytcLr f- 1 N '4 6. -/ Lf <br />(Street Number—Street Name—City—Zip) <br />Name of Contractor(s): {,n ( �–' Phone #: <br />Contractor Company Name: <br />Address of Contractor Company: <br />(Street Number—Street Name—City—Zip) <br />Current Use of Building: -4 <br />(Single Family—Mtrlti-Famib}--Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: V/ 0014 -t—,`0., v'� <br />(Wood Frame—Brick--S�tojne—Steel—Concrete—Other) <br />Proposed Work: (inor•e than one ❑ Landscape ❑ New LJ Replacement (not in-kind) ❑ Demolition <br />box may be checked) <br />Description of Proposed Work: <br />a <br />(e'_ ��0..C.Z %t/1'� (`� G><Ol�� W �h • � Pc Kzi n� i 5S i t)r✓t a-vrc� v 5 ie <br />Ownere-mail: � ��� t J 1 aLl C�Q ' • /or Contractor e -snail: <br />X <br />* and/or X <br />t i ✓(1ij <br />�+9 (A l t.A.4Vt - W Y P -l2 SWMAC <br />eo+ry tVi-Fh (o pa»e.1 stee-l. <br />Signat re of Owner Signature of Contractor <br />By signing flus 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 />