BENSALEM TOWNSHIP
Building and Planning Department
2400 Byberry Road Bensalem, PA 19020
Office 215-633-3644 Fax 215-633-3753
Z
NIN
PERMIT APPLI
ATI
N
A SIGNED COPY OF THIS APPLICATION IS REQUIRED PRIOR TO ISSUANCE OF PERMIT
ZONING OFFICER DECISION ZONING HEARING BOARD DECISION
Approved Denied Approved Denied
Appeal No.
Decision Date:
Zoning Officer Signature Date
Note: Any stipulations or conditions imposed by the Zoning Hearing Board are incorporated in this permit.
Rev 6/2016
Zoning and
Project Data
Building
Characteristics
Applicant’s Name: Phone No:
Address:
Email Address:
Tax Parcel No:
Owner’s Name:
What is Being Built?
Existing Use:
Proposed Use:
Zoning Classification:
SHOW MINIMUM SETBACKS REQUIRED BY MUNICIPAL ZONING ORDINANCE (In Feet)
Front Ft Rear Ft Right Side Ft Left Side Ft
Sq. Ft. of Conditioned Space
Floor Area of Addition (sq. ft.)
Sq. Ft. of Unconditioned Space
Floor Area Renovated (sq. ft.)
Number of Stories Above Grade # of Multi-Family Dwelling Units
Does it have a Basement # of Accessible Dwelling Units
Floor Area of New Construction (sq. ft.)
Description of Work to be Completed:
Square Footage of Lot
Lot Depth
Square Footage of Existing Building
Side Yard No. 1
Square Footage of Proposed Building
Side Yard No. 2
Lot Front Width
Total Side Yards
Height
Front Yard
Impervious Surface Cover
Rear Yard Setback
No. of Stories
Total Building Area - All Floors
Sq. Ft.
Height of Structure
Ft. Volume of Structure
Cu. Ft.
rea - Largest Floor
Sq. Ft. Total Land Area Distributed
Sq. Ft.
Estimated Cost of Building Work: $
I/We do declare under the penalties of perjury, that this application has been examined by me/us; and to the best
of my/our knowledge and belief it is true, correct and complete.
I/We hereby certify and agree that, if a permit is issued, all of the provisions of the building, housing, zoning, and
fire codes of the Township of Bensalem will be complied with, whether herein specified or not; and I/We hereby
agree to save, indemnify and keep harmless the Township of Bensalem against all liabilities judgments, costs and
expenses which may in any way accrue against said Township of Bensalem in consequence of the granting of
the permit or from the use or occupancy of any building, sidewalk, street or sub-sidewalk placed by virtue thereof
and will in all things strictly comply with the conditions of the permit.
Signature Date
Owner Applicant Agent
Permit No:
Date:
