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f <br />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 - Fax 574-235-9578 - Email:- SBSJCHPC@co.st joseph.in us <br />Website: http//www.stjosepheountyi diana.conilsjchp/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received�.ir -�;10 S Application Number 4 _!� I.J - d Yo�,g 4 ? B <br />Past Reviews: LJ Y is(Date of last Review) F-1 NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date:/ / f � A5' <br />E] Local Landmark []2'Local Historic District (Name)GC2�rLc.�t„ ,( <br />F] National Landmark n National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled F] Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work: 1(2)(oll <br />AStreet Number and Street Name (� <br />Name of Property Owner(s): (Please Print) av- k n- <br />Address of Property Owner(s): I D WI 91 V s ',; i Ae C)r 1 j e— <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: {� Phone: <br />Current Use of Building: i <br />(iIfl`(r''�����1 <br />gle Family — Multi -Family Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind E] Landscape � New � Replacement (not in-kind) [] Demolition <br />(more than one box may be checked) F� <br />Descripti n of Proposed Work:/l A da 14 1 r) n0 � k . 1 �' i J e L'00- fx') a- <br />a a ► n 11 <br />7r e e mo tja ( CA) <br />_5 e e /24-lach or dp-Sr-r; (W,1DA -4 dei a r'lS <br />Owner/Contractor: Fax: e-mail k&l Ca 46 b Z V a 100. C 0 VL_7 <br />(This will correspond with only one designee) <br />and/or <br />Sigr�ature o Owner j/ Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />