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Name <br />Sarah Andrews <br />President <br />CITY OF SOUTH BEND <br />AND ST. JOSEPH COUNTY <br />HISTORIC PRESERVATION COMMISSION <br />A Certified Local Government of the National Park Service <br />www.southbendin.gov/hpc <br />Ross Van Overberghe <br />Historic Preservation <br />Administrator <br />Certificate of Appropriateness Contractor Release Form <br />If you are a contractor, sales representative, or office manager for a construction company and wish to apply for a Certificate <br />of Appropriateness (COA) on behalf of a homeowner, please complete this form and attach it to the online application for a <br />Certificate of Appropriateness, This process ensures smooth communication between Staff, contractors, and homeowners. <br />I, the property owner(s), grant the below -mentioned contractor or company permission <br />to submit this application for a Certificate of Appropriateness on my behalf. I certify that <br />understand and am aware of all the proposed works included on this application. <br />Property Address for Proposed Work <br />43- 3.7 Ec4 <br />Street Number <br />Sou A e�c/ <br />City <br />Primary Property Owner(s) <br />Job P 710,2 k , <br /> <br /> <br /> <br /> <br /> <br /> # <br /> <br />70-Jc 'r 5 Co 51/N4r c <br />Company <br />S ?ey'vlP�l 44,- i'-$_9( /9 -6 <br /> <br /> <br />Phone # <br />Date <br />E-mail <br />227 West Jefferson Blvd., Suite 1400S I Ph: 574-235-9371 Fx: 574-235-9021 <br />hpcsbsjc@southbendin.gov <br />