BENSALEM TOWNSHIP
LICENSE
PPLICATION
Building and Planning Department
Office 215-633-3644 Fax 215-633-3753
2400 Byberry Road Bensalem, PA 19020
NON-OWNER OCCUPIED DWELLING UNIT
NEW APPLICATION RENEWAL APPLICATION
Date
License #
Tax Parcel #
Application Year
LOCATION
OWNER’S NAME
OWNER’S ADDRESS
CITY STATE
ZIP
PHONE No.
EMAIL
TOTAL # OF UNITS PAYMENT ENCLOSED $
(#UNITS X $15.00)
NAME OF TENANT(S) UNIT No.
1.
2.
3.
4.
5.
I/We certify that all of the above statements are true and correct to the best of my knowledge, and understand that false
statements are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Owner Signature Title Date
I/We further certify that the person named below, has been designated to act as my legal representative in relation to the above property.
AGENT’S NAME
BUSINESS ADDRESS
MAILING ADDRESS
PHONE No.
Email ADDRESS
I certify that I am the legal agent of the above person/people in relation to the above property and that I am empowered to
accept service of papers, notices, etc. in relation thereto.
Agent/Owner Signature Date
A SIGNED COPY OF THIS APPLICATION IS REQUIRED PRIOR TO ISSUANCE OF PERMIT Rev 10/2014
