JOB INFORMATION
JOB ADDRESS:___________________________________________________________________________________
SUBDIVISION:________________ BLDG ____________ FLOOR ____________ SUITE ____________ MAP ________
LOT ________ TYPE WORK _________________________________________________________________________
WORK DESCRIPTION: _____________________________________________________________________________
BUILDING PERMIT NO.: ____________________
□ RESIDENTIAL □ COMMERCIAL □ GOVERNMENT
GAS TYPE:
□ Natural □ L.P. □ Medical UTILITY CO.:______________ WMS #: _______________
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:______________________________________
GAS KITCHEN EQUIPMENT-
COMMERCIAL
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 .
DATE: __________________________________
CONTRACTOR’S SIGNATURE: __________________________________________________
FIND THIS APPLICATION AND MORE ON THE WEB AT WWW.HARFORDCOUNTYMD.GOV
THIS DOCUMENT AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
Rev. May 2020
DEPARTMENT OF INSPECTIONS,
LICENSES & PERMITS
PLUMBING SERVICES DIVISION
220 SOUTH MAIN STREET
BEL AIR, MD 21014
410-638-3215
410-638-3216
410-879-2000
FUEL GAS PERMIT
APPLICATION
Application Document No. 000341-2020
