SITE INFORMATION

Property Owner of Record

Street Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Owner's Mailing Address (if different)

________________________________________________________

Property Description*

Commercial Use Industrial Use Vacant Land Vacant Structure

Single Family Residential Use Multi-Family Residential Use Owner Occupied Tenant Occupied (rental)

________________________________________________________

General Description of Concern (check all that apply)*

High Grass Inoperative Vehicle Unsafe Structure Trash/Debris

General Nuisance Minimum Housing Zoning

Specific Description*

________________________________________________________

INSPECTION REQUESTED BY:

The names, addresses and phone numbers of complaints furnished in confidence with respect to an investigation of individual zoning, property maintenance or building code complaints made to a local governing body are excluded from the provisions of the Virginia Freedom of Information Act, but may be disclosed by the record custodian at their discretion except where such disclosure is prohibited by law.

Requester:*

Concerned Citizen Tenant/Lessee

City Official Anonymous

Name*

Street Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Phone Number*

Date of Request*