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Sarah Andrews <br />PrCsOcni <br />CITY OF SOUTHBEND <br />AND STJOSEPH COUNTY <br />HISTORIC PRESERVATION COMMISSION <br />A Certified Local Government of the National Park Service (Ross Van Overberghe <br />www.southbendin.gov/hpc 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 />6yr fP-alrk AvGltue <br />Street Number Street Name <br />.S' c., tA74A Rpe m cl( <br />Zip Code <br />Primary Property Owner(s) <br />;?&,0/ `¢ MCAP_S(A LA Al D 3t' <br /> <br /> (if different than above) <br />Signature <br />Contractor Applying for COA <br />Wallace Historic Restoration LLC <br />Company <br />William Wallace 574-256-8446 wallacehistoricrestorationsOgmail.com <br />227 West Jefferson Blvd., Suite 1400S I Ph: 574-235-9371 I Fx: 574-235-9021 I hpcsbsjc@southbendin.gov <br />