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Baytown Custodial Residential Care and Living Permit Application
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Facility Name
*
Facility Physical Address
*
City
State
Zip Code
Facility Mailing Address
City
State
Zip Code
Facility Main Phone Number
*
Facility 24-hour Emergency Phone Number
*
Facility Administrator
*
Office Number
*
Mobile Number
*
Email Address
Driver's License Number and State
*
Number of Occupants
*
Description of Services Provided
*
Facility Owner/Parent Company Name
*
Principal Title
*
Address
City
State
Zip Code
Phone Number
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.
*
I Agree
Electronic Signature of Person responsible for this Facility:
*
Date
*
Date
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 Payment
Online Custodial Care Payment
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