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. J6 <br />Application <br />- for - <br />Certficate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 South Lafayette Boulevard <br />Mailing address: 227 West Jefferson Blvd - South Bend IN 46601-1830 <br />Phone: 219-235-9798 Fax: 219-235-9578 e-mail: historic@michiana.org <br />- A Certified Local Government <br />OFFICE USE ONLY>»»>DO�NNOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received 6 — //2utlb Application Number. 2003 0,0,// <br />Put Reviews: RYES (owricvusrut7aq--�?Y��9S ❑ NO <br />Staff Approval authorized by. C/ Title: <br />Historic Commission Review Date: <br />❑ Local Landmark <br />❑ National Register District al...h <br />XIAWHistoric DistrictCertificate of Approprlateness:' <br />❑ Denled <br />❑ Approved and Issued <br />❑ National Landmark <br />❑ Tabled <br />2002 <br />❑ Sent To Committee <br />Address of Property for proposed work: /D 1/,—, n� , <br />./ if.rAM1�w/37r.rNwr1 <br />City Owner's Phone No: <br />Name of Property Owner(s):rrvNn <br />Address of Property Owner: / 4/D 7 . <br />Contractors) Name: hf, G /A <br />Contract Company Name: /< C /Q <br />Contractor Address: !�) (J,,� (515- <br />51eJ i�C—d'tixS— City: <br />Contractor's Phone No: 2 8 5� – G 7 78 <br />3 3 91 .2 0 33 <br />Current Use of Building: 6m,,- <br />(Siwr4 rind), • X.16-F—dj - Coi— cid - Gem --W -1.&,9, a! - V.c—t - em <br />Type of Building Construction: al;�j <br />(Woof Fres- Bract -Store-Std -C--f. - Otho) <br />Proposed Work: ❑ Inkind ❑ Landscape ❑ New ❑ Replacement( -vi -kind) <br />(.r,e Am ~ b= xw be checbed) ❑ <br />Demolition <br />Description of Proposed Work: 1214- r I'll , . rlv-z - d,��.-9 <br />G' <br />Owner/Contractor: Fax: e-mail: <br />(rue ogles MB cwmpwd wth only a r Agat^w) <br />&/or <br />Sipmrof Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE. <br />