ARCHITECTURAL MODIFICATION FORM
Request for Structural / Landscape Addition or Modification

Name: Date:
Street Address:
Daytime Telephone: Evening Telephone:

DESCRIPTION / DIAGRAM OF MODIFICATION REQUESTED: Please include: site plan (showing sizes and location of improvement to residence and adjoining properties), manufacturer's brochure (if available), color samples (if applicable), grading plan (if applicable), and a detailed description (sketch or picture, if appropriate) of addition or modification. If more space is needed, attach a seperate sheet. I (We) acknowledge and agree that I (we) will be solely liable for any claims, including without limitations, claims for for property damage or personal injury, which may result from the requested addition or modification. I (We) indemnify the Homeowners Association from and against any and all such claims. I (We) understand and acknowledge that I (we) am (are) responsible for complying with all applicable codes and ordinances, and for obtaining all necessary permits and inspections for the requested addition or modification and further that I (we) am (are) responsible for all maintenance, repair and upkeep of said addition or modification.

OWNER: OWNER:

ACTION BY ARCHITECTURAL REVIEW COMMITTEE
Date Received: Notice Sent: [   ] Approved as requested

[   ] Approved subject to the following conditions:
[   ] Disapproved for the following reasons:

Authorizing Signature

Date