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,toe lOtiER50F <br />ad CITY OF SOUTH BEND �yi' Ta <br />o;� <br />\.e e AND ST. JOSEPH COUNTY a <br />a <br />HISTORIC PRESERVATION COMMISSION P�°s�-xv°n <br />ergiffin <br />Sarah And. A Certfied Loral Goyemment of the National Park Service Ross Van Overbation <br />President www.southbendiagov/hpc Historic Preservation <br />on <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 fora <br />Certificate of Appropriateness. This process ensures smooth mmmu nicadon 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 />1321 Wayne St. S <br />Sheet Number 9,eet Nome <br />South Bend 46615 <br />city zv tree <br />Primary Property Owners) <br />Tom Keller <br /> Fdi E. moil <br />eaarenof J1ffeni moo abew, <br />Slgrafure/ Oam 7123M <br />Contractor Applying for COA <br />Hershberger Masonry <br />comes, <br />227 West Jefferson Blvd., Suite 1400S I Ph:574-235-9371 I Fx: 574-235-9021 I hpcsbsic@southbendin.gov <br />