Application Form For Residential Building Permit
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1
2Department of Permitting Services
Division of Building Construction
255 Rockville Pike, 2nd Floor
Rockville, MD 20850-4166
Phone: 311 in Montgomery County or (240) 777-0311
Fax (240)-777-6262
Application for Residential Building Permit
Building AP #(s) ______________ Demolition # _______________
Sediment Control
# _______________
A. Description of Work: (Check all that apply)
ADD
SINGLE FAMILY DWELLING
DECK
ALTER
Gross Sq. Ft. of Area Created
TOWNHOUSE
DUPLEX
or Affected by this Action: ____________
CONSTRUCT
FENCE*
BASEMENT
DEMOLISH
Estimated Cost: $ ___________________
RETAINING WALL
POOL IN GROUND
MOVE
Disturbed Land Area: ________________
TRAILER**
POOL ABOVE GROUND
FOUNDATION ONLY
Lot Size: ___________________
MODULAR HOME**
DETACHED GARAGE
RESTORE and/or REPAIR
HOT TUB
SHED
REVISION
FINAL INSPECTION ONLY
_________________________________________
OTHER
PROPOSED USE OF STRUCTURE:
DAMAGE REPORT
_______________________________________________________
*
For ALL Fence Construction
HEIGHT: __________ ft. __________in.
Note:
(A signed approval letter from the adjacent lot owner(s) is required when on lot line)
Located entirely on the land of the owner
Public Right of Way/Easement
Located on the lot line
**NOTE: ___________________________________________________________________________________________________
Manufacturer’s Name and Model # for All Trailers and Modular Homes
B. Model House Program/Refer-Back System
Model House Program – to build new homes
Refer-Back System – build new homes and pools
or
or
INITIAL SUBMITTAL
INITIAL SUBMITTAL
# __________________
# __________________
PREVIOUSLY APPROVED PERMIT
PREVIOUSLY APPROVED PERMIT
Name or # __________________________________________________________________________
New Home Model
C. Revision
REVISION to ORIGINAL PERMIT # __________________________
(Original permit has been issued and is active)
: ____________________________________
SITE
STRUCTURAL
HOUSE TYPE
OTHER
D. Site Plan Information
MNCPPC Site Plan No.
Preliminary Plan No.________________________________________
_______________________________
Record Plat No. _________________________________
Y
N Forest Conservation Easement?
E. Building Address:
Number__________Street__________________________________________City_____________________________Zip________
Lot (s)
Block ________________________ Subdivision _______________________________
_______________________________
Nearest Cross Street. ________________________________________________________________________________________
F. Applicant Information: Supply all information, incomplete applications will not be accepted.
: ___________
: ________________
Contact ID #
Fax #
Email: _______________________
Name of Applicant ________________________________________________________ Daytime Phone #: ____________________
(Permit will be issued to Applicant)
Address _________________________________________City ______________________State _________ Zip ______________
G. Contact Information: Supply all information, incomplete applications will not be accepted.
___________
Contact ID #:
Fax #: _____________________ Email: ________________________
Contact Person ___________________________________________________________ Daytime Phone # ___________________
(If other than Applicant)
Address _______________________________________ City _____________________ State _________ Zip __________________
Contractor ___________________________________________ MHIC or Montgomery County Builders License # ______________
Contractor Address _______________________________________________________ Daytime Phone # _____________________
Page 1 of 2 Revised 2/21/2012
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