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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 />MaiBng Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574-235-M8 Fax: 574-235-M • Email SBSJCRPC®ao.st joseph mus <br />Website http://www.sgosephaountyindkmcom/ajchp/index.html <br />OFFICE USE ONLY»>>» DO NOT COMPLETE ANY ENTRIES CONARM IN THIS BOX »»» OFTICE USE ONLY - <br />Date Received Application Number <br />Past Reviews: ❑ YES (Otte o/Gat &view) RNO <br />Staff Approval authorized by. %}� Title: <br />Historic Commission Review Date: <br />❑ Local Landmark Gjt1 cal Historic District pvame) ` z <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness:. <br />❑ Denied ❑ Tabled ❑ Sent To Committee [E"Approved and Issued 4&tl" 2010 <br />WE <br />Address of Property for proposed work: 2 z A(n tint? zr F <br />Stmt Number and Stmt Name <br />Name of Property Ow ner(s): (Pime print) „l►4QA'r-, µeR <br />Address of Property Owner(s): 2 o Z 14 A v!-/ Q 1� <br />Contractor(s) Name: V Avl o J v STi e-6 <br />Contract Company Name: % ` 1� Pc:, P i r bf #1 / Af7X- )A.V d c <br />Contractor Address: 1?6 5 t_ a EP 161¢ S':' <br />City: enc 4b6.56 Phone: 57y- Z73- Z /Zo <br />Current Use of Building- A KG 4c <br />(Single Fandly-Multi-FamOy- Commadd - Covemment -Industria! -Vacant - eta) <br />Type of Building Construction: Gt)oav FlUx-4 6 <br />(Wood From - Brkk - Stone - SW - Concrete- Other) <br />Proposed Work ® In-kind Landscape ❑ New [a Replacement (not in kind) ❑ Demolition <br />(more than we box may bedud-ed) L Pare <br />Description of Proposed Work '5 Q LAe,,V Vol - Fa 1Z tN � I- Q •— 00 W _:r AW <br />Owner/Con ctor. Fax: e-mail <br />(This oris tow MWdesignee) <br />xr 7 <br />,e.•- and/or <br />r+'-�� tis Zi � @ to••� c�s�. <br />— APPLICATION REQLUREAE S ARE LISTED ON REVERSE SIDE — <br />