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,3.11 n b� You 1 d <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 />Mailing Address: County -City Building; South Bend, Indiana 46601 <br />Phone. 574 - 235 -9798 • Fax 574 - 235-9578 • Email:: SBSjaiPC®co st josephin.us <br />Website: httF://www.sqosepha)unq*Oiana.cbm/ochp/indexhtird <br />OFFICE USE ONLY » >>>> DO NOT COMPLETE ANY ENTRIES CONnINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received B. I I - Application Number 2Q 11_ - O 10 0 3 <br />Past Reviews: ❑ YES (Date of las Rwiem) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark Local Historic District (Name)T <br />rl National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />(] Denied E] Tabled [] Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work t y I tea•^ 0 ; 7� . S � _ <br />p Str umber Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: y � r^ ca. C_P ( <br />Contractor Addre (A (.f C1 02 <br />City: Phone: 7 M i <br />Current Use of Building- <br />,410",(SingleFamt7y— tt Family-Com ' 1— Government— Industrial— Vacant —etc.) <br />Type of Building Construction. ( C , 7 <br />(Wood Frame — Brick — Stone —Sted — Concrete — Other) <br />Proposed Work: ❑ In -kind ❑ Landscape ❑ New 4ep lacement (not in -kind) E] Demolition <br />(more than one box mtybe cheda4 <br />Descrjption of Proposed Work: �(a "`�` �- -- Q <br />t <br />Owner /Contractor. Fax \ 7 `� I �- 8 e -mail <br />( This o ffia unll corraspond urith onlyone es _) •' <br />_Y, �p—,_ and /or <br />- APPLICATION REQIUREMENIS ARE LISTED ON REVERSE SIDE — <br />