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2. Frederick County Permitting Services Notification for Damage Related to (check one or more):*

   1. Structural
   2. Plumbing (water or gas)
   3. Electrical (not including fixtures, appliances, extension cords, etc.)
6. Business/Residence Name:*
8. Street Address:*
9. Unit/Suite/Apt. #:
11. City*
15. Incident Number*
16. Date and Time*
    Date and Time

    Date and Time
18. Description*
20. Photos Taken*

    1. Yes
    2. No
21. Photos Sent via Separate Email to Ashlye Bonomo at ABonomo@FrederickCountyMD.gov*

    1. Yes
    2. No
25. Submitted by:*
26. Phone
27. Submitter Email*
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field