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REQUEST FOR MODIFICATION OR ADDITION A copy of this form, completed by the ARB, reflecting the action taken by the ARB will be returned to you for your records.

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 follow this request. It must be received by the ARB before this request is considered. If more space is required, please enclose a separate sheet with the diagram, sketch or picture. MAIL TO: Jim Symons 6613 White Post Road Centreville, VA 20121

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:

EMAIL ADDRESS OF OWNER
THIS CONSTITUTES YOUR LEGAL SIGNATURE!