* Full Name:

* Street Address:

* Email Address::

* Phone Number::

* DESCRIPTION/DIAGRAM OF MODIFICATION REQUESTED: Please include a description and diagram (sketch
picture or plat, if appropriate) of addition or modification:

Attach any diagram, picture, or plat, if appropriate:
(No larger than 5MB, only filetypes PDF, JPG, or PNG allowed)

I (We) acknowledge and agree that I (we) will be solely liable for any claims, including and without limitation, for
property damage or personal injury, which results from the requested addition or modification. I (We) hereby 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 building 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.