Owner Information Name of Owner : (*) Please enter the owner's full name. Address : (*) Please enter a valid street address. City : (*) Please enter a valid city. State : (*) --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Please select a state. Zip Code : (*) Please enter a valid zip code. Home Phone : (*) Please enter a valid phone number Business Phone : Please enter a valid phone number. Place of Birth : (*) Please enter the owner's place of birth. Date of Birth : (*) Please enter the owner's date of birth in the correct format (MM/DD/YYYY). Gender : MaleFemale Invalid Input If granted a RENTAL PERMIT, will the owner/manager conform to all laws and regulations relating to the license? (*) YesNo Please select an option.

Property Description Property Type : (*) Rental HomeRooming Homes Please select an option. Use and Occupancy Permit Number : (*) Please enter the permit number. Address : (*) Please enter a valid street address. City : (*) Please enter a valid city. State : (*) --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Please select a state. Zip Code : (*) Please enter a valid zip code. Plat Number : (*) Please enter the plat number. Block Number : (*) Please enter the block number. Lot Number(s) : (*) Please enter the lot number(s). Number of Units Rented : (*) Please enter a valid number. Rental : (*) WeeklyMonthly Please select an option. Rental Fee Collected By : (*) Please enter the name of the person who will be collecting rental fees.

Property Manager Name or Realtor Name : (*) Please enter the name of the property manager. Address : (*) Please enter a valid street address. City : (*) Please enter a valid city. State : (*) --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Please select a state. Zip Code : (*) Please enter a valid zip code. Business Phone : (*) Please enter a valid phone number.

Use & Occupancy Permit	Invalid Input
I hereby affirm that this application contains no willful misrepresentation or falsifications and that this information given by me is true and has been completed to the best of my knowledge. I also hereby grant the town the right to inspect the unit(s) at any reasonable time. You must agree before you submit the form.
Please enter the characters :	Invalid Input

NOTICE: ALL PAYMENTS  or FEES must be in the form of a personal check, corporate check, money order, cashier's check, or certified check made payable to: The Town of Capitol Heights.
NO CASH ACCEPTED!

REMINDER: IF DWELLING WAS BUILT AFTER 1972, please provide the following:

RENTAL PROPERTY: Please provide a copy of the Use & Occupancy Permit for a Single Family dwelling.

ROOMING HOUSE: Please provide a copy of the Use & Occupancy Permit for the Rooming House

APPLICATION: Must be renewed annually and properly inspected by Town Code Enforcement Officer. Late penalties and Violation Penalties will be enforced.