2. 

4. A Zoning Code Compliance Permit is a certification of property use and shall be required for any of the following activities: 

   • Construction, reconstruction, erection, extension, enlargement, conversion or structural alteration of any building, including accessory structures; 
   • Change in use of an existing building or accessory structure to a use of a different classification;
   • Occupancy and use of vacant land and existing structures; 
   • Change in the use of land to a use of a different classification; 
   • Any change in legally nonconforming use;
   • Fences (commercial and residential); and
   • Any temporary uses as defined under the Zoning Ordinance of the Town of Poolesville. 

   A Zoning Code Compliance Permit is issued subject to continued compliance with all requirements and conditions of the Zoning Ordinance and other regulations enacted by the Town of Poolesville, all as in effect at the time of issuance of the Zoning Permit, and may be revoked for noncompliance. 

   All Zoning Code Compliance applications will be approved in accordance with the procedures outlined under Zoning Ordinance 198. 

6. Date*
   Date
8. Applicants Name*
10. Address1*
12. City*
13. State*
14. Zip*
16. Email*
17. Phone*
19. Property Owners Name (if different then applicant)
21. Address1
23. City
24. State
25. Zip
27. Email
28. Phone
30. Legal Description of the Subject Property (list all parcels that apply)
32. Property Address:*
34. Property Area in Square Feet or Acres*
36. Current Zoning:*
38. Type of Construction: (please check)*

    1. New Construction
    2. Addition
    3. Deck
    4. Fence
    5. Shed
    6. Pool
    7. Other
40. If other please explain
42. Description of Work:*
44. Description of Project and Proposed Use(s) of the Property (attach plans):*
46. Upload Plans*
48. Description of the Existing (or Former) Use(s) of the Property:*
50. Proposed Use: (please check)

    1. Single Family
    2. Church
    3. Office
    4. Commercial
52. Questions 10-14 are only applicable to any type of construction activity. If you are not undertaking building activity skip to question 15.
54. 10. Foundation Setbacks (from property lines)
56. Front:
57. Rear:
58. Left Side
59. Right Side
61. 11. Dimensions of Construction:
63. Height:
64. Depth:
65. Width:
66. Stories:
68. 12. Basement:
69. Lot Area:
70. Sq. of Floor space
71. Lot Coverage %
73. 13. Anticipated Start Date:
    13. Anticipated Start Date:
74. Duration of Work:

    in calendar days

76. 14. Water and Sewer
78. Required Sewer Have:
79. Required Sewer Requested
81. Required Water Have:
82. Required Water Requested:
84. Questions 15-19 apply to Commercial Uses/Businesses Only
86. 15. Trade Name:
88. Lessee:
90. Phone:
92. Mailing Address:
94. 16. # of Employees:
95. # of Company Vehicles:
97. If the use is Storage, specify what is to be stored:
99. If the use of mixed, specify the percentage of usage:

    provide both the type of use and the % of the property allocated to each use 

101. 19. Available Parking (# of Spaces)
103. Entire Facility:
104. Allocated to Applicant:
106. 20. Fee Included:

     1. $75.00 – New Construction
     2. $30.00 – Additions, Decks, Pools, etc.
     3. $10.00 – Fence or renovation
     4. $25.00 – Change in Use
108. I hereby certify that the information shown herein is correct, and that the construction will comply with the approved plans, and I hereby acknowledge and accept this to be a condition for the issuance of this permit.*

     1. Yes, I certify that my information is correct
110. Applicant Signature: *
111. Date*
     Date
113. Property Owner’s Signature (if different than Applicant)
114. Date
     Date
Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

* indicates a required field