JOB INFORMATION
JOB A
DDRESS:___________________________________________________________________________________
SUBDIVISION:________________ BLDG ____________ FLOOR ____________ SUITE ____________ MAP ________
LOT ________ TYPE WORK _________________________________________________________________________
WORK DESCRIPTION: _____________________________________________________________________________
BUILDING PERMIT NO.: ____________________
□ RESIDENTIAL □ COMMERCIAL □ GOVERNMENT
OWNER INFORMATION CONTRACTOR INFORMATION
OWNER: ______________________________________ COMPANY: _______________________________________
OCCUPANT: __________________________________ LICENSEE:________________________________________
ADDRESS: ____________________________________ ADDRESS: ________________________________________
CITY: _______________ ST: ______ ZIP: ___________ CITY:__________________ ST: ______ ZIP: _____________
PHONE: ______________________________________ PHONE:___________________________________________
LIC. NO.______________ STATE LIC. NO: _______________
COMMENTS:__________________________________ EMAIL:____________________________________________
_____________________________________________ SIGNATURE:_______________________________________
STORM SEWER/UTILITIES ON SITE
OUTSIDE WATER REPAIR/REPLACEMENT
OUTSIDE SEWER REPAIR/REPLACEMENT
INSIDE PIPE REPAIR/REPLACEMENT
MOBILE HOME CONNECTION (sewer/water)
By submitting this application, the applicant certifies and agrees: (1) That the applicant is authorized to make the application because the applicant is the property owner
or an authorized agent of the property owner; (2) That all the information provided is correct; (3) To comply with all the laws and regulations of Harford County that are
applicable to the request; (4) To perform only the work as specifically described in this application; (5) To grant County officials/employees the right to enter onto the
property for purposes of inspecting the work permitted and posting notices; and (6) currently holds an active license or registration with Harford County Government. In
accordance with Harford County Code §1-22 F, a person who knowingly makes a misrepresentation or false statement on an application for a County permit or license is
guilty of a misdemeanor and, upon conviction, is subject to a fine not exceeding one thousand dollars ($1,000) or imprisonment not exceeding ninety (90) calendar days
or both.
I certify that all materials used in any work performed under a permit issued based on this application shall comply with the requirements for lead-free materials
contained in the Annotated Code of Maryland
CONTRACTOR’S SIGNATURE:_________________________________________________________DATE:_____________________________
FIND THIS APPLICATION AND MORE ON THE WEB AT WWW.HARFORDCOUNTYMD.GOV
THIS DOCUMENT IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
Rev. 05/2020
DEPARTMENT OF INSPECTIONS, LICENSES
& PERMITS
PLUMBING SERVICES DIVISION
220 SOUTH MAIN STREET
BEL AIR, MD 21014
410-638-3215
APPLICATION
Application Document No. 000343-2020
