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Baytown Custodial Residential Care and Living Permit Application
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Facility Physical Address
Facility Mailing Address
Facility Main Phone Number
Facility 24-hour Emergency Phone Number
Driver's License Number and State
Number of Occupants
Description of Services Provided
Facility Owner/Parent Company Name
I hereby apply for a Baytown Custodial Residential Care and Living Permit. I attest that the information contained in this application is true and accurate to the best of my knowledge.
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Electronic Signature of Person responsible for this Facility:
This application must be submitted and a check made payable to the City of Baytown in the amount of $50 for new facilities and $25 for renewals must accompany the Baytown Facility Emergency Operations Plan. Submit Custodial Care Permit payments online. Submit Forms and Plans via email to OEM@baytown.org
Online Custodial Care Payment
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