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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 />7ZI l (7/-C (/L <br />Street Number <br />Street Name <br />.5'01,4711, 1.?roci WPC - <br />City Zip Code <br />Primary Property Owner(s) <br />cLASRI. ) - <br /> <br />Address (if different than above) <br />Signature <br />Contractor Applying for COA <br />may.- --- 6 J 0. <br />Date <br />Company <br />ire / // 47 l /(G C_ 5-71(-- C - gg9V <br />Name ., Phone # E-mail <br />//7&a,„ <br />Signature - <br />Z/ 2—C7 (�cz <br />Date <br />1/ c <br />227 West Jefferson Blvd., Suite 14005 <br />Ph: 574-235-9371 Fx: 574-235-9021 <br />hpcsbsjc@southbendin.gov <br />