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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 />Michele Gelfman, President A Certified Local Government of the National Park Service Adam Toering, Historic <br />Preservation Administrator <br />OFFICE USE ONLY>>>>>>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX<<<<<<OFFICE USE ONLY <br />Date Received: ____________________ Application Number: ____________—___________________________________ <br />Past Reviews: YES (Date of Last Review) _____________________________ NO <br />Staff Approval authorized by: _________________________________________________________ Title: __________________________ <br />Historic Preservation Commission Review Date: __________________________________________________________________________ <br /> Local Landmark Local Historic District (Name) ________________________________________ <br /> National Landmark National Register District (Name) _____________________________________ <br />Certificate Of Appropriateness: <br /> Denied Tabled Sent To Committee Approved and issued: _____________________ <br />Address of Property for proposed work: ________________________________________________________________________ <br /> (Street Number—Street Name—City—Zip) <br />Name of Property Owner(s): __________________________________________________ Phone #: ______________________ <br />Address of Property Owner(s): _______________________________________________________________________________ <br /> (Street Number—Street Name—City—Zip) <br />Name of Contractor(s): _______________________________________________________ Phone #: ______________________ <br />Contractor Company Name: __________________________________________________________________________________ <br />Address of Contractor Company: ______________________________________________________________________________ <br /> (Street Number—Street Name—City—Zip) <br />Current Use of Building: _____________________________________________________________________________________ <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: ________________________________________________________________________________ <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br /> Landscape New Replacement (not in-kind) Demolition Proposed Work: (more than one <br />box may be checked) <br />Description of Proposed Work: _______________________________________________________________________________ <br />___________________________________________________________________________________________________________ <br />___________________________________________________________________________________________________________ <br />___________________________________________________________________________________________________________ <br />Owner e-mail: __________________________________ and/or Contractor e-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, if applicable. <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS