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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 Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 9 Fax: 574-235-9578 • Email SBSJCBPC®oo.st josephinus <br />Website: http://www.sgosephcountyindiamcom/sjchp/index.html <br />OFFICE USE ONLY»s»> DO NOT COMPLETE ANY ENTRIES CONMINEDINTHIS BOX »»» OFFICE USE ONLY <br />Date Received&, f Application Number Z o - n Z& <br />Past Reviews: V YES (Date of Last Review) _ r NO <br />Staff Approval authorized by: h ua b � 1 e ( Title: &i <br />Historic Commission Review Date: <br />[� Local Landmark Local Historic District (Name) —LA)f <br />National Landmark El National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee E] Approved and Issued <br />DATE <br />Address of Property for proposed work: 1, , Qn C. ©Ln WQ,_q, <br />Street Number and blet Name <br />, <br />Name of Property Owner (s): (Please Print) �OLo sect%!GClI AuxalA <br />Address of Property Owner(s): R <br />Contractor(s) Name: PRY Fe_c;r 7D AJ _c e r V % c e S r,-Cxiir' <br />Contract Company Name: Py pe eTo u C, l � w ce S <br />Contractor Address: '96 ! O T-tr w i _17 a t- S' T- <br />City: n- T j.eA / fn't�Z � Phone:aZ 69'- 6VI-a I W <br />Current Use of Building: CO 144w, e -f -67'a. <br />(Single Family— Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: IA7 000 ffpum <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: Vfln-kind ❑ Landscape ❑ New ❑ Replacement (not in -End) E] Demolition <br />(more than one box may be chacked) V <br />Description of Proposed Work: FT* W 00 TQ,,f s� aL <br />fn, t,T f W �n dt ST�e bc,� 0' moa F, fe mo,r soaer 4 <br />Owner/Contractor. e-mail fV <br />(This cfflaffill correspond onl onedestgnee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />