Permit preparation

Historic Preservation Contractor Release Form

Historic Preservation Commission · St. Joseph County, Indiana

Editable official PDF

Edit the agency’s original form, save your draft, attach documents, and review your completed PDF before signing or ordering delivery.

Print and mail service is available for your prepared packet. Review the destination and the agency’s acceptance requirements before ordering. Government payment is separate from document and postage charges.

Supporting document requires two distinct signers and attachment to the online COA application; no standalone postal submission route verified.

Official form and instructions

Your application steps6 steps · Historic Preservation CommissionView steps

1Prepare your answersComplete here
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2Add supporting documentsComplete here
Attach the supporting records listed by the agency. Check that every page is legible and complete.
3Review and signPrepare here, finish outside
Complete each applicable applicant signature after reviewing the full declarations. Required notary, professional and witness signatures remain separate.
4Choose paymentPrepare here, finish outside
No fixed fee is published in the reviewed form; confirm any applicable charge with the agency. Government fees are separate from the optional prepared PDF and postage. Review the exact amount and recipient before authorizing a check.
5Submit or order deliveryPrepare here, finish outside
Property owner authorizes contractor/company to submit a Certificate of Appropriateness application. Both property-owner and contractor sections must be completed and signed by the actual parties. Attach the signed release to the online Certificate of Appropriateness application.
Official submission instructions
6Keep your receiptComplete here
Save your agency confirmation and payment receipt. Track any mailing from My applications. Delivery does not mean the agency approved your application.

Official requirements and sources

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Introductory instructions require attachment to online COA application. Both owner and contractor signatures provided.

Complete your application

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Page 1 of 1 · 12 editable blanks

City of South Bend and St. Joseph County HISTORIC PRESERVATION COMMISSION Ross Van Overberghe Sarah Andrews A Certified Local Government of the National Park Service Historic Preservation President www.southbendin.gov/hpc Administrator 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 227 West Jefferson Blvd., Suite 1400S Ph: 574-235-9371 Fx: 574-235-9021 hpcsbsjc@southbendin.gov

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Review every page before signing. Professional, agency and notary signature areas stay reserved.Original blank form