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r r <br />Application <br />- for - <br />Certi Kate 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: Wstoric@niicWarLa.org <br />A Certified Local Government <br />OFFICE USE ONLY»» 130 NOT COMPLETE ANY ENTRIES CONTAINED IN T1llS « « «OFFICEUSEONLY <br />Date Received "o, 15 200 Application Number. 2001V 03'l5• <br />Past Reviews: ❑ YES (oArEoFtAsrRs;7_ -; 1 ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: 11 <br />Local Landmark ❑ National Landmark <br />ff National Register District pv): <br />❑ Local Historic District ov— ): <br />Certificate of Appropriateness: <br />❑ Denled ❑ Tabled ❑ Sent To Committee <br />❑ Approved and issued 2002 <br />J <br />Address of Property for proposed work: 1 Y 3 0 `� ��� � 1)� l4 � It lti 61f _A <br />p _ ` / 5— ) <br />bd —dS-dN <br />City: � F /T* 0J (!;,- (3 Owner's Phone No: �; 7 V 2 7 7 f 0 <br />Name of Property Owner(s):mRlxn <br />Address of Property Owner : ) L) 0 c� <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: City: <br />Contractor's Phone No: <br />Current Use of Building: <br />(SinQ/e Fmnily- SfuiC- Familr•Conunoaa! •Indumia!- Vacant -ut <br />Type of Building Construction: bo Q F,`� / - 1 1—: <br />(Wood Frmne -Un * - Scone- Sted- Conoen -Orha) <br />Proposed Work: ❑ Inkind ❑ Landscape PkNew ❑ Replacement(na1in - kid) <br />(coon Nan one bo1: may be checked) <br />❑ Demolition n <br />Description of Proposed Work: /0 f= W G / 't <br />(6 0 e 1' r,(1,4 Ll/ 1 f ) A• <br />Owner! ntractor: Fax: �- 3 �y' U g e -mail: S N J ��► "' ® _ <br />10 n cm'vpond mth only ne den S—) <br />Signature of Owner ( Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE. <br />