Queen Anne’s County PERMIT#
160 Coursevall Drive
DATE OF APPLICATION:Centreville, MD 21617
BUILDING APPLICATION
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BUILDING LOCATION TAX ACCOUNT# TAX CARD# SUBDIVISION CRITICAL AREA SECTION BLOCK LOT TAX MAP GRID PARCEL ACREAGE ZONED FRONTAGE DEPTH |
PROPERTY OWNERS NAME & ADDRESS
HOME PHONE WORK PHONE OWNER ON RECORD |
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EXISTING USE PROPOSED USE |
CONSTRUCTION VALUE ZONING FEE BUILDING FEE SCHOOL FEE FIRE FEE |
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LICENSE # TELEPHONE# BUILDER ADDRESS PLUMBER ELECTRICIAN MECHANICAL |
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DESCRIPTION OF WORK |
STAKED? YES NO WILL CALL |
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BUILDING DESCRIPTION DIMENSIONS (IN SQUARE FEET) |
CONSTRUCTION TYPE |
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UNFIN. BASEMENT FIN. BASEMENT FIRST FLOOR SECOND FLOOR GARAGE CARPORT DECK PORCH OTHER FIREPLACE TOTAL FLOOR AREA |
IMPROVEMENTS #BEDROOMS #BATHROOMS #ROAD ENTRANCES WIDTH ROAD TYPE WATER TYPE SEWER TYPE HEATING SYSTEM CENTRAL AIR SPRINKLER SYSTEM |
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THE UNDERSIGNED HEREBY CERTIFIES AND AGREES AS FOLLOWS (1) THAT HE/SHE IS AUTHORIZED TO MAKE THIS APPLICATION; (2) THAT THE INFORMATION IS CORRECT; (3) THAT HE/SHE WILL COMPLY WITH ALL REGULATIONS OF QUEEN ANNE’S COUNTY WHICH ARE APPLICABLE THERETO; (4) THAT HE/SHE WILL PERFORM NO WORK ON THE ABOVE REFERENCED PROPERTY NOT SPECIFICALLY DESCRIBED IN THIS APPLICATION; (5) THAT HE/SHE GRANTS COUNTY OFFICIALS THE RIGHT TO ENTER ONTO THIS PROPERTY FOR THE PURPOSE OF INSPECTING THE WORK PERMITTED AND POSTING NOTICES. |
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Separate electrical and plumbing permits are required! Plumber and
Electrician must have Queen Anne’s County License.
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APPLICANT’S SIGNATURE ________________________________________________
MINIMUM YARD REQUIREMENTS OFFICE USE ONLY
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ACCESSORY
STRUCTURE |
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PRINCIPLE
STRUCTURE |
APPROVALS | ||
| BUILDING | LD. PL. ZN. | ||||
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FRONT SIDE REAR SIDE ST MAX HGHT. |
FT FT FT FT FT |
FRONT SIDE REAR SIDE ST MAX HGHT |
FT FT FT FT FT |
ZONING SEDIMENT PUB SEW. S.W. MG ENTRANCE |
PLUMBING SANITATION SHA OTHER OTHER |
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COMMENTS: |
DATE APPROVED ____________________________________ ADMINISTRATOR
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