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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 />Mailing Address: County -City DULL ng, SBend, Indiana 46601 <br />Phone: 574235-9798 - Fax: 574-235-9578 - Email: SB5JCHPC )mst joseph mus <br />Website: http://wwwstpmph°ountyindiana.e°m/gchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONIIUNED IN THIS BOX """OFFICE USE ONLY <br />R <br />Date Received I 0 Application Number. X a. <br />Past Reviews: ❑ YES (Ohre of Gut Review) ❑ NO <br />p h <br />Staff Approval authorized by:,��f�� Q {✓A(tlnW Title: f�V <br />Historic Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) E • W a n - <br />❑ National Landmark ❑ National Register District ¢varve) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />onTs <br />..•� n-� <br />Address of Property for proposed work <br />rat Num and Street Name <br />,O <br />Name of Property Owner(s): (Please print) <br />Address of Property Owner(s): <br />���4► ``�" <br />Contractor(s) Name:/f��� <br />Contract Company game: <br />Contractor Address: Y* d <br />City: Phone: <br />�! <br />Current Use of Building: 97F` <br />' <br />/(single FamrTy – Multi -Fa mercial – Government – Industrial –Vacant – etc.) <br />� <br />Type of Building Construction: % �� u%, .i 5�. ape)( ? <br />(Wood Frame – Brick – Sbh –Steel – Connell – Other) <br />Proposed Work ❑ Ln -kind ❑ Landscape E]New Replacement (not in-kind) ❑ Demolition <br />Q. <br />�0�a <br />(more than one box may 6e dwdm) <br />Description of Proposed Work) <br />4eo W 1 <br />Owner/Contractor. Fax: 1-3` 7T e-mail <br />(This o& rraspm�d wilh onlyonedesigmx) <br />and/or <br />CATION RE uTREMENT S ARE LISTED ON REVERSE SIDE — <br />