RESIDENTIAL BUILDING PERMIT APPLICATION

Transcription

1 Butler Twnship 290 Suth Duffy Rad Butler, PA / Fax: 724/ RESIDENTIAL BUILDING PERMIT APPLICATION Name f Applicant Name f Owner Phne Fax Phne Fax Name f Cntractr/C. Name f Architect Phne Fax Phne Fax Lcatin f Prperty (Including lt #, plan, and street name) Size f Prperty Descriptin f Cnstructin Activity and Number f Stries Type f Permit requested (Check all that apply): Building Electrical Fire Prtectin Mechanical Plumbing Demlitin Estimated Cst f Cnstructin Is Wrker s Cmpensatin Certificate prvided with this Applicatin? Yes N Is Applicant Exempt (Ntarized statement required)? Yes N Map & Parcel # Zning District I hereby acknwledge that the infrmatin cntained herein is true and crrect, and I hereby agree t cmply with all applicable prvisins f Butler Twnship s Cdified Ordinance. Signature f Applicant Date f Applicatin Print Name **Please submit tw (2) sets f plans with yur cmpleted submissin** **Please check with yur Hmewner s Assciatin prir t applying fr any building/zning permits.

2 (FOR TOWNSHIP USE ONLY) Ttal Square Ftage Building Permit Fee ZHB# (If Applicable) Cnstructin Type Classificatin Fldplain: Yes N Building Use Classificatin Setbacks: Frnt Rear Left Side Right Side Lt Cverage Cnditins f Issuance Building Cde Official Apprval Date

3 Butler Twnship Wrkers Cmpensatin Infrmatin If the hmewner is the cntractr, please cmplete the fllwing and stp at the dtted line. I,, am the hmewner and am Exempt frm (Print Name) Wrkers Cmpensatin. Hmewner s Signature Date If the hmewner is nt the cntractr fr the building permit, the cntractr in cmpliance with Act 44 f 1993, hereby submits the fllwing infrmatin. Please check ne f the fllwing: A current Certificate f Insurance shwing prf f Wrkers Cmpensatin is attached t this frm. The certificate must indicate Butler Twnship as the certificate hlder. Signature required belw, but des nt need ntarized. The building permit cntractr qualifies as Exempt frm Wrkers Cmpensatin. Please indicate the reasn fr the exemptin by shading in ne f the fllwing. Cmplete the bx belw and get ntarized. Cntractr is a Sle Prprietr withut emplyees. All f the cntractr s emplyees n the prject are exempt n religius grunds under Sectin f the Act. Explain in detail: attach as necessary. Cntractr is a crpratin, and the nly emplyees wrking n the prject have and are qualified as Executive Emplyees under Sectin 104 f the Act. Explain the status f any/r all wrkers n the prject: attach as necessary. Name f Cntractr / Cmpany: : City State Zip Cde 1. Any subcntractrs used n this prject will be required t carry their wn wrkers cmpensatin cverage. 2. The applicant is nt permitted t emply any individual t perfrm wrk n this prject pursuant t the permit in vilatin f the Act. 3. Vilatin f the Wrkers Cmpensatin Act r the terms f this permit will subject the applicant t a stp-wrk rder and ther fines and penalties prvided by law. Cntractr Signature: Date: Subscribed and swrn t befre me this day f, 20. Signature f Ntary Public My Cmmissin Expires

4 PROPERTY OWNER AUTHORIZATION I,, d hereby authrize Prperty Owner s Name Printed Acting Agent s Name Printed t act n my behalf in applying fr a Building Permit fr the fllwing wrk: t be perfrmed at where cnstructin will ccur Prperty Owner s Signature Prperty Owner s Street Prperty Owner s City, State, Zip Cde Date

5 SAMPLE SHOWING PLOT PLAN Rear Yard Deck Side Yard Dwelling Side Yard Prch Frnt Yard Right f-way Cartway r Rad Right f-way