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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/govemment/department/communi ty-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 Patio Service Adam Toering, Historic <br />Preservation Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLYS» >>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX-—OFFICE USE ONLY <br />I Date Received: <br />Application Number: — <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />❑ Local Historic District (Name) . <br />❑ National Register District (Name) <br />❑ NO <br />Title: <br />Certificate Of AppffDenied <br />ateness: <br />❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: 7 A t, gpr"') �F �0"t 4 <br />(Street Number —Street Name —City —Zip) <br />Name of Property Owner(s): <br />Wn � <br />A4�KV1M 6 <br />A4tt'0FV" <br />4 401 <br />Phone #: 5N 339 '? R1 <br />Address of Property Owner(s): 7 )lt V11 E -4p✓flf b°W 13 �ila(v�a <br />(Street umber —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: Slt ,d� `/r1" [,r <br />(Single Family— ulli-Family—Com ercial--Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame —Brick —Stone —Steel —Concrete —Other) <br />Proposed Work: (more than one ❑ Landscape ❑ New 121 Replacement (not in -kind) ❑ Demolition <br />box may be checked) <br />Description of Proposed Work: PC e r'ef <br />Owner c. ail: QV� Q yltI� 0.. wo9-V-j and/or Contractor e-mail: — — <br />X and/or X <br />Signature of WAjr 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 />