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Application <br />- FOR - <br />Certi f icate 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 Buildin. South Bend, Indiana 46601 <br />Phone: 574-2.35-9798 • Fax: 574-235-9578 • Email: SBSJamco.st joseph.in.us <br />Website: http://www.sgosephcountyindiana.com/ochp/index.hhnl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CON7AZNED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received ,41011 Application Number —"— of- <br />Past Reviews: ❑ YES (Date of Gat Review) EKO <br />Staff Approval authorized by. Title: <br />Historic Commission Review Date: <br />❑ Local Landmark 2f cal Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee [D-�kpproved and Issued <br />DATE <br />Address of Property for proposed work: <br />Name of Property Owner(s): (Please Print) <br />SOS- N. L- -Ian � <br />/ t t Number and Street Name <br />Address of Property Owner(s): 't5'Z- /mac_0®,,-cg A ( e • i s- �• �� r (� <br />Contractor(s) Name: 10 Sc A re V in <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building. �� <br />(Single Famii-MultiFamil Commercial -Government -Industrial -Vacant -etc.) <br />Type of Building Construction: <br />( oodFrame Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: (In-kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) I <br />Descriptio.. of Proposed Work: R e '4' -JL <br />Owner/Contractor. Fax e-mail La keJ P Gi 0- CMQ � I . a rvt <br />(This olio: will cornVand with only one designee) <br />_ and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />