12/01/2015 12:13 FAX

I ARLINGTON COUNTY, VIRGINIA ,HISTORICAL AFFAIRS AND LANDMARK REVIEW BOARDAPPLICATION FOR CERTIFICATE OF APPROPRIATENllsS

date-HD RPC#

Designated Property:

Name ofHistoric District ^^^

Address ofBuilding S7~

(To Be Completed By Staff)

OWNER:

Name i ^iJ/LCI4^5^AAddress (ifdifferent)

Phone (Home)Email:

(Work) "^03

Person Filing Application, if other than owner:

Name

Address

Phone (Home)

Relationship to Applicant

Project Architect/Engineers/Contractors;

(Work)

Purpose of Application:

Repair (change of materials)

^Demolition

Tree Removal

^Alteration

X New construction

Grading

_Addition

.Relocation

_Sign

Fence

_Outbuildings

Other

Will an application related to this property go before any of the following? Board ofZoning AppealsPlanning Commission County Board Other (please specify)

Does the proposed work require a building permit? YES NO

Is any demolition anticipated? YES NO Ifyes, please describe

@002

OVERVIEW OF Proposed Work (Attach Additional Sheets if necessary):Description: d4M6£ cx>bF

Revised December 2014

2004 APPROVED HALRB DRAWINGS