Call, email or print and mail the form below along with any plans to:

 Polk Place Modifications Request Form

Date: _______  Section: __________________________  Owner(s): _____________________________

Address: _______________________________________________________________ 

Home Phone: _____________Work Phone: ____________ FAX: ____________  E-Mail: ____________

Nature of Improvement: ________________________________________________________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

As a prerequisite to consideration for approval, and prior to the commencement of the contemplated work, I have attached a complete set of building plans and specifications. 

If approved, I agree to build in accordance with this application and the attached plans and specifications. 

Signed: _____________________________________________________________________________ 

 FOR INTERNAL USE ONLY

APPROVED: ______________________    DISAPPROVED: _____________________ 

MORE INFO REQ’D: ___________________________________________________________________

BOARD OR COMMITTEE MEMBER APPROVAL/DISAPPROVALS: (NAME/DATE) 

_________________________________________________________________________

 COMMENTS:

_________________________________________________________________________

_________________________________________________________________________