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HISTORIC PRESERVATION COMMISSION <br />t OF SOUTH BEND AND ST. JOSEPH COUNTY <br />4' cc County—City Building, South Bend, IN 46601 <br />http:/hvww.soutlibendin.gov/governineiit/department/Commutiity-investment <br />1865 >x Y Phone: 574/235.9371 Fax: 574/235.9021 <br />Email: irpcsbsjc@soutlibendin.gov <br />Michele Gelfinan, President A Certified Local Government of the National Pmic Scivice Elicia teasel, Historic Preservation <br />Administrator <br />APPLICATION FOR A -= CERTIFICATE OF APPROPRIATENESS <br />OFFICE USE OWL I»»>DO `N07' COitiIPLETE ANl' 1;NT RIES CON I AINJ✓D II\' THIS ilOfi«««OFFICE USE ONLY <br />Date Received: <br />Application Number: <br />Past Reviews: ❑ YES (Date of Last Review) ; ❑ NO <br />Staff Approval authorized by <br />Title: <br />Histm•ic Preservation Commission Review Date: <br />Local Landmark <br />❑ Local Historic District (Naind) <br />❑ National Landmark <br />❑ National Register District (Name) <br />Certificate OfAppro riateness: <br />tJ Denled ❑ Tabled <br />❑ Sent To Committee ❑ Approved and issued: <br />Address of Property for proposed work: _ -Dt� �' �� + Gff.�(' Sf. So 04 — V461S <br />(Stree�rmber—Street 1Vni e—City--Zip) <br />Nance of Property Owner(s): <br />Address of Property Owner(s): <br />Name of Contractor(s): _ <br />Contractor Company Name: <br />Address of Contractor Company: <br />Current Use of Building: <br />Type of Building Construction: <br />• <br />• <br />Phone #:`7' <br />n�. Blvd . <br />(Street Alumber—Street Name -Cite --Zip) <br />0i'e,;elc[jt^ Sb Se.Gbaj ©Ro <br />(.Single Iu►tuly—hfitlti=Fcurlil�r—Cot:rruercial—Goveryrl»crit—lircli�.rtrial-l/.rrn,ti—ern 1 <br />(I f ood Fi•ame Brick--Slone--Steel—Concrete—011ier) <br />Proposed Work: (more than one Landsct11te � ( ) <br />hoxanay be checked) ❑ New ❑ Replacement not in-kind Denpolition <br />Deseltiption of Proposed Work: <br />Owner e-mail: and/or Contractor unapt: i?h 1 S ra U.0 <br />X and/ot• X <br />Signature of Owner Sial r of Contractor <br />BY signing this application I agree to abide by all local regulations related to projcet and to obtain Buildutg Department Pennit, ifopplicable. <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />