HomeMy WebLinkAboutContractor COA Form - Digital SignatureCity of South Bend
and St. JoSeph County
HISTORIC PRESERVATION COMMISSION
Sarah Andrews
President
A Certified Local Government of the National Park Service
www.southbendin.gov/hpc
Ross Van Overberghe
Historic Preservation
Administrator
227 West Jefferson Blvd., Suite 1400S | Ph: 574-235-9371 | Fx: 574-235-9021 | hpcsbsjc@southbendin.gov
Certificate of Appropriateness Contractor Release Form
If you are a contractor, sales representative, or office manager for a construction company and wish to apply for a Certificate
of Appropriateness (COA) on behalf of a homeowner, please complete this form and attach it to the online application for a
Certificate of Appropriateness. This process ensures smooth communication between Staff, contractors, and homeowners.
I, the property owner(s), grant the below-mentioned contractor or company permission
to submit this application for a Certificate of Appropriateness on my behalf. I certify that
I understand and am aware of all the proposed works included on this application.
Property Address for Proposed Work
Street Number Street Name
City Zip Code
Primary Property Owner(s)
Name Phone # Primary E-mail
Address (if different than above)
Signature Date
Contractor Applying for COA
Company
Name Phone # E-mail
Signature Date