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f <br />Application <br />- FOR - <br />Certificate of Appropriateftess <br />Historic Preservation Commission of South Bend 8t St. Joseph County <br />125 S. I. -layette Blvd., !36uth Bend, Indiana 46601 <br />Mailing Address: CountSY-City Building, South Bend, Indiana AAM1 <br />Phone: 574-235-9798 • Fax: 574-235-9578 . - Email SBSJCI-IPC@co.st joseph.irLus <br />Website: http://wwwsgo-wphcountyindiana.com/schp/indexbttnl <br />OFFICE USE ON .Y>>>> > DO NOT COMPLETE ANY ENTRIES COMMINED IN THIS SOX >>>>> OFF -ICE USE ONLY <br />Date ReceivedjunC AppIication Numbed{) u t - 04 01A <br />Past Reviews: [TYES (Dat,of last Rtoiew) At t. V r6 0 NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: +21 07-0/4 <br />i <br />C] Local Landmark ] Local Historic District (Name) Y � <br />(] National Landmark Stational Register District (Name) t <br />t <br />Certificate of Appropriateness: <br />E]Denied []Tabled Sent To Committee C] Approved and Issued <br />DATT <br />Address of Property for proposed work: <br />Street Nu and Street Name <br />Name of Property Owner(s): (Please Print) 104poe n j ma `V 'III.c,,e. <br />Address of Property Owner(s): 95.E --P'd "e�s� Ivd <br />Contractor(s) Name: CnyIn+,04C (be I <br />Contract Company Name:'belb'T.t, t alx c(srap ,k Gl c1/L• 00" <br />Contractor Address: X49 L; x -col A wo_4 w <br />City: %b re' kowSa..t7 r -L , Phone: 8'.7 `, -= : %f -- q Y cry-' <br />Current Use of Building:i Xw o t .ak.",/,,�i <br />(Single Family — Multi -Family — Commercial — Got ernment — Industrial — Vacant — eteJ <br />Type of Building Construction: ___W D tact ` /it Q <br />i <br />(Wool Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: In-kind D'q"z Landscape F] New F� Replacement (not in-kiml) F] Demolition <br />Mw thatI Otte tx= Inay IV Checked) <br />Description of Proposed Work: =7AA5r,¢L.L #M /8X 14 , 2,elcx P-4VC-P_ tAn6 <br />b <br />1 N .i'E,Rn or 0q47&,50r 05ltva P /Are A014 L.G. Boer c,< /M <,.fAX t 1L a eee. %l <br />4'7' lAt R ;I.477_6A!A1 <br />Owner/Contractor: Fax: 6 j V _ a 5S_ 6-43q q e-mail <br />(T11is t }cr gcd�tl rurreslx��r i11t only one designe<) — <br />��� and/or <br />a <br />— APPLICATION REQUIREMENTS ARI: LISTED ON REVERSE SIDE — <br />