Rev 3/2016
Permit #
Date
Fee
Owner’s Name:
Address:
Phone No: Email:
Contractor’s Name:
Address:
Phone No: Fax No:
Location of Property:
Tax Parcel No.:
02 -
Additional Information:
NOTE: For every tree removed, a new tree of 2½-inch minimum diameter caliper and species as listed in Section
201-106 of the Bensalem Township Code shall be planted in a location approved by the Township.
A copy of a site plan showing the following must be attached hereto:
Property boundaries with dimensions
Abutting street(s), address and tax parcel number
Location, species and caliper of tree(s) to be removed
Location, species and caliper of replacement tree(s)
Existing sewer and water laterals*
CALL BEFORE YOU DIG PENNSYLVANIA ONE CALL SYSTEM
*Owner must call 1-800-242-1776
rior to an
excavations.
Signature of Owner
Date
OFFICE USE ONLY
Township Engineer’s Recommendation:
Township of Bensalem Department of Building and Planning
BENSALEM TOWNSHIP
Building and Planning Department
Office 215-633-3644 ▪ Fax 215-633-3753
2400 Byberry Road ▪ Bensalem, PA 19020
SHADE TREE REMOVAL
PPLICATION
