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Application <br />- FOR - <br />Certificate icate o f 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 • Fay 574-235-9578 • Emal- SBSjCHPC®m st josephin us <br />Website: htgr//wwwsgosephaountyindiana.cnm/ochp/index htnd <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTIINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received A411 Application Number <br />Past Reviews: ❑ YES (Date of wt Reuiem) ❑ NO <br />Staff Approval authorized by: ( i Title: <br />Historic Commission Review Date: <br />❑ Local Landmark �ocal Historic District (lvanu) i�a-,O'e� Ac _ <br />❑ National Landmark MXational Register District (ivan:4 <br />Certificate of Appropriateness: c <br />❑ Denied ❑ Tabled ❑ Sent To Committee -Approved and Issued <br />' DATE <br />Address of Property for proposed work: ) Q Z <br />,/ Stmt N' and S at Name <br />Name of Property Owner(s): (Piense Print) 4--GY`(�i L) r �^ k 'D v r au. -E - <br />Address of Property Owner(s): $ t)Z V6 re <br />Contractor(s) Name:,Yc <br />Contract Company Name: V1 41 <br />Contractor Address: <br />City: S U ��-� Phone: <br />Current Use of Building• t^ �'� <br />(singleramily-MuittFam: -Commercial-Government-Industrial-Vacant-etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick -Stone - Steel - Concrete -Other) <br />Proposed Work:j�In-kind ❑ Landscape E] New E] Replacement (not in-kind) [:]Demolition <br />(more than one box may bedrak , <br />Description of Proposed Work: Y ° <br />Owner/Contractor: Fax e-mail <br />(This offig un71 rorregwo with only one designs) <br />V�.� and/or <br />- APPLICATION REQIIIREME1M ARE LISTED ON REVERSE SIDE — <br />