Designation of Responsible Agent Application

Address *

City *

State *
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Zip *

First Name *

Last Name *

Address *

Owner City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Phone

Alternate Phone

Email *

Property Owner Signature:

First Name *

Last Name *

Address *

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Phone

Alternate Phone

Email *

Designated Agent Signature:

Please be advised that the City of Williamsport has passed an Ordinance, which took effect on May 19, 1999. The Ordinance requires that every owner of a residential property in the City of Williamsport who resides outside the County of Lycoming name a responsible agent. The responsible agent shall reside or maintain a place of business within the County of Lycoming. They shall receive notices and communications on behalf of the owner necessary for the enforcement of the Proper Maintenance Code.
This form must be and completed and signed by both parties and returned to the Bureau of Codes within 30 days. If you have any questions please feel free to contact our office at (570) 327-7517. Failure to comply with this notice shall subject you to penalties provided for by law. Your cooperation in this matter will be greatly appreciated.
Any owner or operator, who subsequently changes his/her place of residences and resides outside Lycoming County or changes the Designation of a responsible agent, shall notify the Bureau of Codes within thirty (30) days of such change.