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Application <br />- FOR - <br />CeW f i'cate 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: SBSJC ipmco.st josephinus <br />Website. http:// www. sgosephcouniyindiana .com /ochp /index.hbA <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONruNED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received t5. - I I Application Number 2-0 1 1- 0 6 D q <br />Past Reviews: F1 YES (Date of Last Pmew) ❑ NO <br />Staff Approval authorized by. Title: <br />Historic Commission Review Date: <br />Local Landmark Local Historic District (Name) Chia I11 1 'Qr� <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />Denied ❑ Tabled ❑ Sent To Committee 11 Approved and Issued <br />Address of Property for proposed work: (0 2 <br />DATE <br />Street Number and Street Name l <br />Name of Property Owner(s): (Please print) Ot A -1- `'/ <br />Address of Property Owner(s): <br />1 <br />Contractor(s) Name: <br />r � <br />Contract Company Name: <br />Contractor Address: <br />%a ' <br />City- l� <br />Current Use of Building:- - - <br />(Single Family - Multi - Commercial - Government - Industrial - V int - etc.) <br />Type of Building Construction: / 2 2N. <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: n [_1 Landscape E] New ❑ Replacement (not in - kind) ❑ Demolition <br />(nun than one box may be checked) <br />Description of Proposed Work:_ 3+qb <br />Owner /Co actor: Fax:`� �-�_ �� 7 `�`7 e -mail <br />(77ruo/fiac to pon�� ly°"e <br />and /or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />