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U <br />OCT - 12018 <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/govemment/department/community-investment <br />Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@southbendin.gov <br />J0yj <br />1� C C.� <br />Timothy S. Klusczinski, President A Certified Local Goverment of the National Park Service Elicia Feasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLPS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN TILS BOX«««OFFICE USE ONLY <br />Date Received: Z j Application Number: 22 U f — i e O( C <br />Past Reviews: 19 YES (Date ofLast Review) ElNO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: '( )1 -� Ti& <br />10 Local Landmark ❑ Local Historic District (Naive) <br />❑ National Landmark <br />Certificate Of App ro riateness: <br />M Denied ❑ Tabled <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: Saio(r/ji„L�x��sTt%i �%L �21�t;2 /A%0 �GS 30 <br />J(Street Number --Street Name—City—Zip) <br />// <br />Name of Property Owner(s): �n Y' b U, 5 SC -,'7L Phone #: JF /l/% <br />Address of Property Owner(s): ash /y /-/ OBD CT �l� ry/f�y5/3(��G W1 7 f//Z- <br />(Street Number—Street Name—Cit),,—Zip) <br />Name of Contractor(s): d cFF toam '�& ��� Phone #: f <br />Contractor Company Name: A4C _end yltlyCa Awe af- tJJ 114V �2°Sl7�fa 1dN <br />Address of Contractor Company: <br />(Street Number—Street Name—aty—Zip) <br />Current Use of Building: <br />(Single Family—Mul Family—Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: 4kao �'� � /H� .� 4!�C� ��2✓C�d2t <br />(Wood Frame Brzck—Stone—Steel—Cwicrete—Other) <br />Proposed Work: RIn-Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ,Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: /l�Cl%i <br />)11ij6 © �jl 1 AUET and/or Contractor e-mail: /T�l � i/ lei . r=PA <br />Ownere-mail: � ---,— <br />X /¢ �--� and/or X <br />Signature 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, ifapplicable. <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />