Rev. 2/13/2014
Borough of Bellefonte
Fee: $300.00 Date:
Applicant’s Address: Tax Parcel No.
Phone: Email:
Owner of Record:
Address: Tax Parcel No.
Phone: Email:
I hereby apply to the Bellefonte Borough Council for a Grant of Easement:
Please answer and complete all of the following information before returning to the Borough office.
1. Location of Municipal R-O-W for which Easement is requested:
2. Current Zoning District
3. Reason for requested Easement
4. Applicant shall provide signature on application and all submitted documents including but not
limited to:
a. Drawing showing property, size of property, abutting property owners, proposed easement
location and set back lines.
b. Other pertinent data.
I/We certify that the above information is correct and further agree to reimburse Bellefonte Borough for
the cost of engineering services, materials testing, and other site inspections as required by Bellefonte
Respectfully submitted,
(Signature of Applicant) (Date)