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Application <br />Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Address:Mailing <br />t -U Building,C-4k Pe"A Indiana AAAnj <br />Phone: 574-235-9798 * Fax: 574-235-9578 9 Email: historic@n-dchiana.org <br />Website: http://commuiiityn-dd-dana.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY >>>>>> DQ NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX >>>>>> OFFICE USE ONLY <br />Date Received 001(y4lzootj Application Number ;` 0 0 14 Lj <br />Past Reviews: Fj YES (Date of last Review) Fj NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: � <br />Local Landmark. /in Local Historic District (Name) t <br />Fj National Landmark � National Register District (Name) <br />Certificate of Appropriateness: <br />F� Denied F� Tabled [] Sent To Committee M Approved and Issued DATE <br />Address of Property for proposed work: <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />106,q P_iV_r-1Z:s1P6 Opu6- <br />Street Numbcr and Street Name <br />64-m-c)F4Ae,g- <br />F4 t;F- e -S (PC: p9— <br />City: Phone: <br />Current Use of Building: 51 ri r lr Goo-' I L- y <br />(Single Family –Multi -Family – Commercial – Government – Industrial – Vacant – etc.) <br />Type of Building Construction: Gj 0,.:) o �P_A-A C' <br />(WoodFrame – Brick – Stone – Steel – Concrete – Other) <br />Proposed Work: ❑ In-kind �Landscape P<New � Replacement (not in-kind) F] Demolition <br />(More than one box nuzy be checked) <br />Description of Proposed Work: <br />Err 5r I k -1c, 59ftce-; 'PATIOP-A`rl 0^1 <br />Owner/Contractor: Fax: e-mail C <br />(This office u'l correspond tifith only one designee) <br />and/or <br />S191tature of Owtiiert Signature of Contractor <br />— APPLICATION REQLuREN=S ARE LISTED ON REVERSE SIDE — <br />