THE SECOND GATE POST ESTATES HOMEOWNERS' ASSOCIATION

REQUEST FOR MODIFICATION OR ADDITION

NOTE: Please submit an original and two (2) copies of this form. A copy of this form, completed by the ARB, reflecting the action taken by the ARB will be returned to you for your records. 



       MAIL TO:      Jim Symons
                             6613 White Post Road
                             Centreville, VA  20121
OWNERS NAME: ___________________________________________________________

DAYTIME PHONE #: _________________ EVENING PHONE #: _________________

HOME ADDRESS: __________________________________________ LOT#: ________

DESCRIPTION OF MODIFICATION OR ADDITION REQUESTED

Please describe in clear concise language the modification or addition that you wish to make to your dwelling or grounds. A diagram, sketch or picture must be attached to this request. If more space is required, please use a separate sheet.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

I acknowledge and agree that I will be solely liable for any claims, including without limitation, claims for property damage or personal injury, which result from the change or addition. I hereby indemnify the ARB of the Gate Post Estates II Homeowners Association from and against any and all applicable codes and ordinances with regard to obtaining all necessary permits and inspection for the requested modification or addition. I also accept full responsibility for the maintenance, repair and upkeep of said modification or addition.

________________________ ____________________________________________________
DATE SIGNATURE OF OWNER
****************************************************************************

ACTION BY THE ARCHETECTURAL REVIEW BOARD
( ) Approved as requested
( ) Approved subject to the following conditions/modifications:

_____________________________________________________________________________

( ) Disapproved for the following reasons:

_____________________________________________________________________________

Copy returned to Owner on: ________________ ________________________________
DATE Signature of ARB

[HOME] [ARB REQUEST]
1