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CITY OF SOUTH BEND <br />AND ST. JOSEPH COUNTY <br />r865 . HISTORIC PRESERVATION CONJ V ISSION <br />Sarah Andrews <br />President <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 />I understand and am aware of all the proposed works included on this application. <br />Property Address for Proposed Work <br />8 27 Ft. cP-34 4 e- <br />Sheet Number <br />City <br />Primary Property Owner(s) <br />e44 <br />Name <br />Cap <br /> <br />Street Name <br />l CI C� <br />Zip Code <br />r5? <br /> <br /> <br />Contractor Applying for COA <br />&.k-el/ ce cse- <br />Company <br />ker/ 73 ?y Q8 -0'J52 <br />Nome <br />Phone # <br />e iZef z6, <br />Date <br />E-mail p <br />215 S. Dr. Martin Luther King Jr. Blvd. Ph: 574-235-9371 <br />hpcsbsjc@southbendin.gov <br />