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2. Permit Extension Request Application
4. Where applicable, note current contact information where different from issued Permit.
6. Permittee
8. Last Name (Principal Contact):*
9. First Name (Principal Contact):*
10. Middle Name (Principal Contact):
12. Address:*
14. City:*
15. State:*
16. Zip Code:*
18. Email Address:*
20. Primary Phone Number (Home/Mobile/Work)*
22. Secondary Phone Number (Home/Mobile/Work):
24. Property Owner (Permittee if leave blank)
26. Last Name
27. First Name:
28. Middle Name:
30. Address:
32. City:
33. State:
34. Zip Code:
36. Primary Phone (Home/Mobile/Work):
38. Secondary Phone Number (Home/Mobile/Work):
40. General Contract (Property Owner If Left Blank)
42. Company Name:
43. Contact Name:
45. Address:
47. City:
48. State:
49. Zip Code:
51. Primary Phone Number:
52. Secondary Phone Number:
54. HB Reg. #/ MD MHIC #
56. Electrical Contactor (Property Own if Left Blank)
58. Company Name:
59. Electrician(s) Name:
61. Address:
63. City:
64. State:
65. Zip Code:
67. Primary Phone Number:
68. Secondary Phone Number:
70. MD Master License #
72. Plumbing Contractor (Property Owner If Left Blank)
74. Company Name:
75. Plumber(s) Name:
77. Address:
79. City:
80. State:
81. Zip Code:
83. Please respond to the following questions:
85. (Building Code Year) Date of original Permit: CY
87. Expiration Date of SEC Plan (if applicable):

    Include Year

89. Expiration Date of Maryland W.W.C.P. (if applicable):

    Include Year

91. Has authorized work commenced:

    1. Yes
    2. No
93. Date Commenced:

    Include Year

95. If yes, and applicable, have building code inspection(s) been conducted “on-schedule”?

    1. Yes
    2. No
    3. N/A
97. I hereby request Permit Validity Extension through (date):

    Include Year

99. Permittee’s reason/justification for Permit validity extension request:
101. Attach building code inspection reports, if applicable.
103. Attach copy of issued Permit:
105. Attach copy of approved Site Plan
107. Check If Item Is Not Available

     1. Site Plan
     2. Permit
109. Certification
111. I hereby agree to comply with all regulations and codes, which are applicable hereto. I further agree that any misstatement or misrepresentation of facts presented as part of this extension request, or change to proposal without approval of the agencies concerned, shall constitute sufficient grounds for the disapproval or revocation of the subject permit. I hereby affirm that I own the property which is the subject of this application; or that I am the duly designated representative of the property owner, and that I possess the legal authority to make this Affidavit on behalf of myself or the owner for whom I am acting. I do solemnly declare and affirm under the penalties of perjury that the contents of this request are true and correct to the best of my knowledge, information and belief.*

     1. I agree
Leave This Blank:


113. 1. Receive an email copy of this form.
114. Email address

     This field is not part of the form submission.

115. Submit Submit and Print

* indicates a required field