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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://wwNv.southbendin.gov/government/department/community-investment <br />Phone:574/235.9371 Fax:574/235.9021 <br />Email: hpcsbsjc@south ben din. gov <br />Sarah Andrews, President A Certified Local Government of the National Patio Service Adam Toering, Historic <br />Preservation Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CON'TAI:NEI) IN' TTIIS BO\«««OFFICE USE ONLY <br />Date Received: <br />Application Number: <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Appr•oval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate Of Appro riateness: <br />f Denied ❑ Tabled <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ NO <br />Title: <br />❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: PC— K AYZ `' t� T <br />f / (Sheetm Number—Slreet Name —City —Zip) Name <br />Name of Property Owner(s): V - Phone #: S / V <br />Address of Property Owner(s): 30> �� S-F '"'- �/ J d] yb4. / 7 <br />(Streel Nunzbei=Sd•eet ,Vame—Cily—Zip) <br />Name of Contractor(s): kH u C(- I Phone #: <br />Contractor Company Name: �C�' 1� ���� I t +r�j / f" <br />Address of Contractor Company: <br />�~ ��nj(Streel Ntanbei=Streel Nanie—City—Zip) <br />Current Use of Building: ilm K <br />(Single Fuiziiiiii.—ritulIti,-pFcanili,—Conznzercial—Governnient—Indiislrial—Vacant—etc) <br />Type of Building Construction: � ( � ;( /'�'� <br />(Mood Frame —Brick —Stone —Steel —Concrete —Other) <br />Proposed Work: (inoire than one Landscape ❑ New ❑ Replacement (not in -kind) ❑ Demolition <br />box may be checked) <br />Description of Proposed Work: <br />woodwork. <br />r <br />Owner e-mail: <br />X <br />Signature of Owner <br />54�F ?90_T� <br />and/or Contractor a-mai . ' <br /> <br />and/or X <br />Sign <br />By signing this application I agree to abide by all local regulations related to project jm/Lo obtain a Building Department Permit, if applicable <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />