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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. Klusczinski, 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: �, (i . Application Number: } ° t piJ � L i�ti <br />Past Reviews: ❑ YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: } Title: <br />Historic Preservation Commission Review Date: 14' ' 2.{� <br />❑ Local LandmarkLocal Historic District.(Name)r� quo <br />❑ National Landmark 1:1 National Register District (Name) <br />Certificate OfAppro riateness: <br />Denied ❑ Tabled Dent 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 />Number --Street Name—City—Zip) <br />(Street Number—Street <br />Phone#: S'(p19_-It, A <br />L� <br />G <br />Name of Contractor(s): Cl/� U Ni d2e!'? Phone #: <br />Contractor Company Name: �� rJ—�/ r� oaY/ <br />Address of Contractor Company: <br />(Street Number—Street Name—City—Zip) <br />Current Use of Building: t `l xP / lll% ` G <br />ingle Family—Multi- amily—Connnercial—Government Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind 11Landscape ❑ New 11�y Replacement (not in-kind) —IRDemolition <br />(more than one box may be checked) <br />Description of Proposed Work: /i% <br />Own e- ail:/ G r f ! / 'brand/or Contractor e-mail: • <br />,• <br />-7 y and/or X <br />SigAlture f 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, if applicable. <br />