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Sarah Andrews, President <br />Ross Van Overberghe, <br />Historic Preservation Administrator <br />APPLICATION FOR A — CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE ONLYy»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: <br />Past Reviews: <br />Application Number: <br />❑ YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate Of Appro riateness: <br />Denied <br />Title: <br />E <br />Local Historic District (Name) <br />National Register District (Name) <br />❑ Tabled ❑ Sent 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 />Name of Contractor(s): <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/departm ent/community-investment <br />Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: hpcsbsjc@southbendin.gov <br />A Certified Local Government of the National Park Service <br />ti 105 Q/K Kcl So h Bend 1 N 4140 <br />(Street Number —Street Name —City —Zip) <br />Scan 1u1�11ar <br />Phone #: <br />bl1b5 QoKILSou+h Bend 1N 4fe6(b <br />(Street Number —Street Name —City —Zip) <br />Abby Nut <br />Contractor Company Name: P 3 CnStO&11Oi <br />Phone #: 57y . ‘7LJ..L d <br />Address of Contractor Company: 14n 4l yUO rk1 °date, Wel W otO rust 1 N 11eg 73 <br />(Street Number —Street Name —City —Zip) <br />Current Use of Building: Sin/ <br />Type of Building Construction: <br />F <br />( gle Family—Mult amily Commercial —Government —Industrial —Vacant —etc. <br />V4Z FrQmw, <br />(Wood Frame —Brick —Stone Steel —Concrete --Other) <br />Proposed Work: (more than one <br />box may be checked) <br />Description of Proposed Work: <br />f�S1O t t 1 Synt jh c <br />31.Oi1S <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> signing this application I agree to abide by all local regulations related to project and to obtain a Building Depamnent Permit, if applicable. <br />• MIT r1+ A m11116.r rtr•. llr Trrl r!1Rr]r•rT0 a UbI r romr'n AILT rrr!vnrbor• 0111117 <br />