Jermyn Rental Permit Application

JERMYN BOROUGH
440 Jefferson Ave. Jermyn, PA 18433
Phone: 570-876-0610
Fax: 570-876-0204
Fax:
RENTAL PERMIT APPLICATION (Please complete Front & Back)

Permit Fee - $40.00 per dwelling unit
New Application
Renewal Application
Property Owner:
Name:
Address:
Phone:
Mobile:
Rental Unit Information:
Number of Rental Units:
Occupants per unit:
Handicapped persons per Unit:
Pets per unit:
Single
Double
Multi-Unit
**List Names of All Occupants 18 and Older**
(Use separate paper if more lines required)
**Jermyn Borough Ordinance requires a LOCAL AGENT if owner does not live within a

twenty (20) mile radius of the Borough.**
Local Agent:
Name of Agent:
Signature of Authorized Local Agent

Clear
Date

MonthDayYear
Date
Attachments Required:
Certificate of Insurance:
** A permit will not be issued if a copy of insurance for the property is not provided ** No permit shall be issued to an owner or agent whose property tax, garbage or sewer fee is delinquent as defined by each agency

I swear or affirm that my statement and answers above are true and complete to the best of my knowledge and belief. I also realize that I will be subject to criminal penalties provided by 18PA.CS.4903 and 4904 if I have provided false answers and statements.

Payments must be made prior to permit issuance – Make checks payable to: Jermyn Borough. Cash, Checks, Credit Cards* Accepted (Visa, Mastercard, Discover only)

*Credit Card Payments are charged the higher of 2.95% or $2.50 service fee by the credit card processor
Signature of Owner or Authorized Agent:

Clear
Date:

MonthDayYear
Date
Should be Empty:

JERMYN BOROUGH

Phone: 570-876-0610

Fax: 570-876-0204

Property Owner:

Rental Unit Information:

Local Agent:

Attachments Required: