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City of South Bend <br />and St. JoSeph County <br />HISTORIC PRESERVATION COMMISSION <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 />227 West Jefferson Blvd., Suite 1400S | Ph: 574-235-9371 | Fx: 574-235-9021 | hpcsbsjc@southbendin.gov <br />Certificate of Appropriateness Contractor Release Form <br />If you are a contractor, sales representative, or ofÏce 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 />Street Number Street Name <br />City Zip Code <br />Primary Property Owner(s) <br />Name Phone # Primary E-mail <br /> <br /> Date <br />Contractor Applying for COA <br />Company <br />Name Phone # E-mail <br />Signature Date <br />1312 E E wayne S <br />south bend 46615 <br />Kate Simeri <br />Smith and company custom fence LLC <br />Jesse Smith 269-591-0380 Smithandco.fence@gmail.com <br />08-05-2026 <br />Verified by pdfFiller <br />08/05/2026 <br />Docusign Envelope ID: 7B20B2AA-AFEC-87C6-8032-6A72C2429C99 <br />08-05-2026