ROAD OPENING PERMIT APPLICATION
THIS PERMIT IS REQUIRED FOR WORK WITHIN THE RIGHT-OF-WAY OF A PUBLIC STREET OR TOWNSHIP EASEMENT
PERMIT AUTOMATICALLY EXPIRES NINETY (90) DAYS AFTER APPROVAL IF NOT PICKED UP
ISSUE DATE:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATE RECEIVED:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PROPERTY ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
APPLICATION DATE:
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
APPLICANT NAME:
*
First Name
Last Name
PHONE:
*
Format: (000) 000-0000.
APPLICANT ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARCEL IDENTIFICATION NUMBER
*
EMAIL:
example@example.com
An application is hereby made for a permit for construction as indicated herein and which shall be located as shown on the plot plan submitted herewith and/or to use the premises for the purpose herein described. Applicant agrees that such work will comply with all applicable provisions Ordinances of the Township of Worcester.
APPLICANT SIGNATURE:
*
IF THIS APPLICATION IS NOT BY THE PROPERTY OWNER, THEN BY WHAT AUTHORITY:
CONTRACTOR NAME:
*
First Name
Last Name
PHONE:
*
Format: (000) 000-0000.
CONTRACTOR ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CELL:
Format: (000) 000-0000.
EMAIL:
example@example.com
PROPERTY OWNER NAME:
*
First Name
Last Name
PHONE:
*
Format: (000) 000-0000.
OWNER ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FAX/CELL:
Format: (000) 000-0000.
EMAIL:
example@example.com
WORK WITHIN A STREET RIGHT-OF-WAY
Road Opening/Right-of-Way Encroachment
New Driveway/Widening Existing Driveway
Sidewalk Installation/Replacement
Square footage inside pavement =
Square footage outside pavement =
Total Square footage =
WORK WITHIN A TOWNSHIP EASEMENT
Road Opening/Right-of-Way Encroachment
New Driveway/Widening Existing Driveway
Sidewalk Installation/Replacement
Square footage inside pavement =
Square footage outside pavement =
Total Square footage =
APPROVAL STATUS
APPROVED
DENIED
FEES:
Application Fee $
Escrow $
Check #
PERMIT EXPIRES:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Check #
CONDITIONS OF APPROVAL:
TOTAL $
Check #
PERMIT ISSUED BY:
TITLE:
DATE:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Pa One Call Serial #
*
Date:
*
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Starting Date:
*
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate Completion Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
All work to be done in accordance and subject to Worcester Code Chapter 126 (Street and Sidewalks), PA Act 38 (PA One Call), and all other conditions, restrictions and regulations prescribed by the Township of Worcester with the same force and effect as if written or printed here and under and subject to special conditions, restrictions, and regulations may be imposed by the Township.
I/We agree to protect, defend, indemnify and save harmless the Township, Officer or Agents thereof, from all claims, suits, actions and proceedings of every nature and description whatsoever which may be brought against the Township Officers or Agents thereof, for or on account of injuries or damages to persons and/or public or private property, due to any materials or applications an in the work or by account of improper materials of workmanship, or for on account of any accident or any other act, negligence or omissions of said applicant or his agents, servants or employees, and the Township shall not in any way be liable therefore. The applicant is (1) that person or persons who will be doing the work; or (2) the property owner.
APPLICANT NAME:
*
First Name
Last Name
APPLICANT SIGNATURE:
*
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