APPLICATION FOR BUILDING PERMIT / USE CERTIFICATE

APPLICATION FOR BUILDING PERMIT / USE CERTIFICATE
Applicable Codes: 2009 IBC/IRC, 2012 IBC Chapter 11, 2009 ICC A11 7.1 Please print legibly - failure to do so may result in a denial, delay or rejection of this application.
Permit Application Date

MonthDayYear
Date
Permit Application No
Owner
Tax Map
Site Address
Parcel No
Municipality
County
Use Permit No
Single-Family Dwelling / Duplex

2. BUILDING OWNER'S INFORMATION
First Name
Mi
Last Name
Phone No
Address

Street Address

Street Address Line 2

CityState

Zip
3. BUILDING PERMIT APPLICATION
Provide below description of Work Also provide details on plot plan Show all improvements on lot approx distances to lot lines
AcresSq Ft
ESTIMATED COST OF CONSTRUCTION
ICC Use Group
ICC Construction Type
I certify that I am the owner of record, or that I have been authorized by the owner of record to submit this application and that the work described has been authorized by the owner of record. I understand and assume responsibility for the establishment of official property lines for required setbacks prior to the start of construction, and agree to conform to all applicable local, state, and federal laws governing the execution of this project. I certify that the Code official or his representative shall have the authority to enter the areas in which this work is being performed, at any reasonable hour, to enforce the provisions of the Codes governing this project. I further certify that this information is true and correct to the best of my knowledge and belief. Ref. 18 Pa. Cons. Stat. § 4903.
APPLICANT SIGNATURE

Clear
PRINT NAME legibly
Address
Phone No.
Please list additional general contractor information on additional sheet(s) if needed.
Phone No
City
State
Zip
Person in Charge of Work
Phone No.
Email
example@example.com
Cell No
Workman's Compensation Insurance:Provided

ExemptPA Home Improvement Contr. Reg. #
PA Home Improvement Contr Reg
Fire Suppression/Fire Alarm System
Heat Source if applicable
Fuel Type
Please list subcontractors for major trades. Use additional sheet(s) if needed.
Contractor
Address
Pa HIC
Phone No
Contractor
Address
Pa HIC
Phone No
Contractor
Address
Phone No
Pa HIC
Contractor
Address
Pa HIC
Phone No
Contractor
Address
Pa HIC
Phone No
APPLICATION FEE
ISSUANCE DATE
PERMIT FEE
EXPIRATION DATE
INSPECTION FEES
EXTENSION DATE
TOTAL FEES
APPLICATION IS:GRANTED
DENIED
INCOMPLETE:
SIGNATURE OF PERMIT OFFICER

Clear
DATE
APPLICANT OR AUTHORIZED AGENT IS RESPONSIBLE FOR CONTACTING BUILDING INSPECTOR FOR REQUIRED INSPECTIONS.

All permit submissions must have drawings or prints attached
File Upload

Cancelof
Should be Empty:

APPLICATION FOR BUILDING PERMIT / USE CERTIFICATE

ISSUANCE DATE

EXPIRATION DATE

EXTENSION DATE

TOTAL FEES

APPLICATION IS:GRANTED

DENIED

INCOMPLETE:

DATE