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