Application Form For Residential Building Permit Page 2
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1
2H. Applying for “Design for Life”
If applying for “Design for Life” certification, indicate the level of accessibility
Visit-Able
Live-Able
CERTIFICATE NAME:
I. Additional Approvals:
Properties located within historic districts, municipalities and special taxing districts may require additional approvals
beyond the required Department of Permitting Services (DPS) building permit.
For projects located in the City of Takoma Park’s Commercial Revitalization Overlay, certain permits must be approved by
the City prior to commencing construction.
Please refer to “Permit Procedures for Properties within a Montgomery County Municipality” for more information.
J. Water and Sewage
OTHER (specify) ___________________
TYPE OF WATER SUPPLY
WSSC
WELL
SEWAGE DISPOSAL
WSSC
SEPTIC
OTHER (specify) ___________________
K. MPDU (moderately priced dwelling unit(s))
20% of this new home development will be built as Moderately Priced Dwelling Units
Yes
No
L. Special Exception: Is this lot subject to a Special Exception?
,
Yes
Case # _____________
No
M. Variance: (Has a Variance been granted to perform this work?
_________
Yes, Variance #
No
N. Historic Area in Atlas or Master Plan: Is the property a Historic resource?
Yes
No
O. Authorized Agent Affidavit:
I hereby declare and affirm, under penalty of perjury, that:
1. I am duly authorized to make this permit application on behalf of: __________________________________________
(Please print property owner’s name)
2. The work proposed by this building permit application is authorized by the property owner; and
3. All matters and facts set forth in this Affidavit are true and correct to the best of my knowledge, information and belief.
__________________________________________________
____________________________________
(
Property Owner’s Signature)
Date
(Print Name)
__________________________________________________
____________________________________
(
Authorized Agent’s Signature)
Date
(Print Name)
P. Statement of Homeowner Acting as New Home Builder:
I, the undersigned property owner, state that I am not a licensed new home builder and that the building to be constructed
under this permit is to be used as a residence for me and my immediate family. I will serve as general contractor and take
responsibility for compliance with all applicable building codes.
________________________________________________
____________________________________
(
Property Owner’s Signature)
Date
(Print Name)
Q. To Be Read by the Applicant:
Any information that the applicant has set forth in this application that is false or misleading may result in the rejection of
the application. A condition for the issuance of this permit is that the proposed construction will comply at all times with
the plans as approved by all applicable government agencies.
__________________________________________________
____________________________________
(Applicant’s Signature)
Date
(Print Name)
R. Expedited Plan Review:
I request an Expedited Plan Review, when available, which is subjected to additional fees.
_____________________________________________________
______________________________________
(Applicant’s Signature)
Date
(Print Name)
Page 2 of 2 Revised 2/21/2012
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