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Application <br />- FOR - <br />Certi ficate 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: SBSJCHPC@co.st joseph.inus <br />Website: hq://www.st osephcounq indim&com/sjchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CON7}IINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received4� 620 /U APPlication Number �O 1 O <br />Past Reviews: ❑ YES (Date of Last Rwiew) BfiO <br />Staff Approval authorized by: r�e�:CY • Title: <br />Historic Commission Review Date: <br />❑ Local Landmark RlCocal Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee �pproved and Issued �� •'2o�U <br />DATE <br />Address of Property for proposed work: ` 1 , . Uj , `i M1-tZ:1 < <br />r� Street Number and Street Name <br />Name of Property Owner(s): (Please Print) C�C:� <br />Address of Property Owner(s): <br />Contractor(s) Name: iA. v--> 0 c:, 7---, 'j? t:5c ,ter l r\i % C._ A ✓ .V (C O <br />Contract Company Name: <br />Contractor Address: 7 <br />City: N"-- X' S wk G -V w ALC A Phone: � Z C4 - Cca '7 4 <br />Current Use of Building: , N Co I— YA (" L + C—( <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: 1 %-.)�t7 i—i2.✓-.-, . - <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: Xln-kind ❑ Landscape ❑ New ❑ Replacement (not in-kind)❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: l -V2- ` 0 F Z- - R 00 'i::� (-• 0 Lt S:> t_=- <br />Zr- (:;-'A l_ <_S(7:� c2� t <br />Owner/Contractor: Fax: 2 , y "7_ � �7) & . e-mail <br />(This office will correspond with only one designee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />