Building & Zoning Permit Application
Location of Proposed Work or Improvement
Municipality: ___________________________________________________ Borough Township
Site Address: _____________________________________________ Tax Parcel: __________________
City: ___________________________________ State:_____________ Zip Code: _________________
Zoning District: __________________________________ Lot Size: _____________________________
Property Owner(s): _____________________________________________________________________
Mailing Address: ________________________________________________________________
City: _________________________________ State:___________ Zip Code: _______________
Phone Number: ______________________ Email Address: ______________________________
Principal Contractor: ___________________________________________________________________
Mailing Address: ________________________________________________________________
City: _________________________________ State:___________ Zip Code: _______________
Phone Number: ______________________ Email Address: ______________________________
Design Professional / Architect: ___________________________________________________________
Mailing Address: ________________________________________________________________
City: _________________________________ State:___________ Zip Code: _______________
Phone Number: ______________________ Email Address: ______________________________
Type of Work or Improvement
Zoning Permit Only
New Building Addition Fire Protection Repair Energy Electrical
Mechanical Plumbing Change of Use Alteration Manufactured Housing
Swimming Pool Deck
Description of the Proposed Work: __________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Estimated Cost of Construction (Reasonable Fair Market Value)
Structural Cost $ __________________________
Installations Not Included in Above Cost
Electrical $ __________________________
Plumbing $ __________________________
HVAC $ __________________________
Total Project Cost $ __________________________
Description of Building Use
Residential Uses Non-Residential Uses
One-Family Dwelling (R-3) Specific Use: _______________________________
Two-Family Dwelling (R-2) Use Group: _________________________________
Multi-Family Dwelling (R-2) Change in Use: Yes No
Hotel (R-1) If Yes, Indicate Former: _______________________
Maximum Occupant Load: _____________________
Maximum Live Load: _________________________
Building Dimensions
Existing Building Area: ________________ sq. ft. Number of Stories: ___________________________
Proposed Building Area: _______________ sq. ft High of Structure Above Grade: ______________ ft.
Total Building Area: __________________ sq. ft. Area of Largest Floor: ___________________ sq. ft.
Building / Site Characteristics
Number of Residential Dwelling Units: ____________ Existing ____________ Proposed
Mechanical System - Indicate Type (i.e. Electric, Gas, Oil, etc.): _________________________________
Water Service: Public Private
Sanitary Service: Public Private On-Lot Sanitary Permit #: _____________________
Does or will your building contain any of the following:
Fireplace(s): Number _______ Type of Fuel _______ BTU’s _______ Vent Type _______
Elevator / Escalator / Lift / Moving Walk
Sprinkler System
Pressure Vessel
Refrigeration System
Floodplain Development
Is the site located within an identified Special Flood Hazard Area? Yes No
Will any portion of the Special Flood Hazard Area be Developed? Yes No
Owner and/or agent shall verify that any proposed development activity complies with the requirements
of the National Flood Insurance Program, the Pennsylvania Flood Plain Management Act (Act 166-1978),
and any flood plain ordinance adopted by the municipality.
Applicant Certification
The applicant certifies that all information on this application is correct and the work will be completed in
accordance with the "approved" construction documents and PA Act 45 (Uniform Construction Code) and
any additional approved building code requirements or zoning ordinance adopted by the Municipality.
The property owner and applicant assumes the responsibility of locating all property lines, setback lines,
easements, rights-of way, flood areas, etc. Issuance of a permit and approval of construction documents
shall not be construed as authority to violate, cancel or set aside any provisions of the codes or ordinances
of the Municipality or any other governing body. The applicant certifies he/she understands all the
applicable codes, ordinances and regulations. Application for a permit shall be made by the owner or
lessee of the building or structure, or agent of either, or by the registered design professional employed in
connection with the proposed work.
I certify that the code administrator or the code administrator's authorized representative shall have the
authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the
code(s) applicable to such permit.
I certify that I am aware of the municipality’s inspection requirements and have received a copy of the
required inspections. Furthermore, I am aware that all inspections must be completed before a certificate
of occupancy will be issued. I may not occupy the structure, for any purpose, prior to the issuance of a
certificate. The installation of finishing materials or pouring of concrete slabs prior to the completion of
required rough inspections will result in the need to remove any material to gain access to allow the
inspection. Neither the jurisdiction nor the building official is liable for expenses entailed in the removal
or replacement of any material required to allow inspection.
I certify that I am aware that a copy of the approved plans must remain at the construction site at all times
until the project is complete and a certificate of occupancy has been issued. Additionally, I am aware that
a copy of the building permit shall be kept on the site of the work until the completion of the project.
________________________________________ ________________________________________
Signature of Owner or Authorized Agent Print Name of Owner or Authorized Agent
__________________________________________________________ _________________________
Address Date:
I would like to receive my permit electronically (residential permits only)
Email Address: __________________________________________________________________
Required Project Documents:
The following must be submitted to be considered a complete application:
A plot plan must accompany the application indicating location of new construction and
measurements to all lots lines.
A Certificate of Insurance showing proof of General Liability Insurance for work performed by a
contractor.
An Affidavit of Exemption or Proof of Workers Compensation Insurance.
Payment of the required Application Fee.
Construction Documents: non-residential projects must have construction documents prepared,
signed, and sealed by an Architect or Engineer. Construction documents shall not exceed 24”x36” in
size. Three (3) copies of the construction documents must be submitted for non-residential projects.
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FOR MUNICIPAL OFFICE USE ONLY
PERMIT NUMBER:____________________________________ DATE:_____________________________
T
OTAL FEE: $________________________ COLLECTED BY:____________________________________
F
EE BREAKDOWN:PLAN REVIEW: $________________
ACCESSIBILITY: $________________
BUILDING: $________________
P
LUMBING: $________________
M
ECHANICAL: $________________
ELECTRICAL: $________________
FIRE PROTECTION: $________________
ENERGY: $________________
D
CED: $________________
Z
ONING: $________________
MUNICIPAL FEE: $________________
CONDITIONAL USE APPROVAL REQUIRED: ( ) YES ( ) NO
PLANNING COMMISSION MEETING DATE: ___________________________________________
GOVERNING BODY MEETING DATE: ___________________________________________
ZONING VARIANCE REQUIRED: ( ) YES ( ) NO
ZONING HEARING BOARD MEETING DATE: _____________________________________
CONTRACTORS GENERAL LIABILITY INSURANCE ON FILE: ( ) YES ( ) NO
CONTRACTORS WORKMANS COMPENSATION INSURANCE ON FILE: ( ) YES ( ) NO
IF NO, IS NOTARIZED CERTIFICATE OF EXEMPTION ON FILE: ( ) YES ( ) NO
IS PROPOSED PROJECT LOCATED WITHIN A SPECIAL FLOOD HAZARD AREA:( ) YES ( ) NO
IF YES, WHICH ZONE: _____________________________________
PERMIT APPROVAL
APPROVED ( ) DISAPPROVED ( ) __________________________________ DATE: ______________
BUILDING CODE OFFICIAL
APPROVED ( ) DISAPPROVED ( ) __________________________________ DATE: ______________
ZONING OFFICER