Land Use Permit Checklist Form
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1►LAND USE PERMIT CHECKLIST◄
NOTE TO APPLICANT: Applicable items on this checklist shall be completed prior to your submission of an application for a building permit. Failure to
complete any applicable item on this checklist shall be sufficient grounds for denial of the building permit application. Please contact your local
municipal office or the local Pa Municipal Code Alliance, Inc. office if you have any questions about the process for obtaining a building permit.
Municipality
County
Tax Parcel I.D.
Land Use Permit #
Location of Property/Work Site (Complete Address Street City Zip)
NAME AND CONTACT INFORMATION OF THE APPLICANT:
Print Full Name
Phone (Cell and/or Land line)
Email Address
Complete Mailing Address:
Street/P.O. Box
City
State
Zip
Type of Construction:
Single-Family Dwelling / Duplex
Multi Family
New Manufactured Home
Relocated Manufactured Home
Commercial
Other _____________________________________
Improvement Type:
New
Addition
Alteration
Repair/Replacement
Relocation
Other ______________________
Estimated start date ___________________
Estimated date of completion __________________
Estimated value of construction _______________
Number of Additional Bedrooms_____________
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, and I 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 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 laws of this jurisdiction. I further certify that this information is true and correct to the best of my knowledge.
Applicant’s signature __________________________________________ Date___________________
Checklist of preliminary requirements for obtaining a building permit, approvals to be obtained prior to applying for a building permit. All items must be
addressed. Mark N/A for those that are not applicable. Attach extra sheets if necessary to identify special requirements or conditions.
Sewage facilities planning module, DEP Planning Code # __________,
Date of approval ____________
Sub-division & Land Development, Municipal resolution # _________,
Date of approval ____________
Sewage permit from Sewage Enforcement Officer, Permit # ________,
Date of approval ____________
Storm water management module. Approved by: _________________,
Date of approval ____________
Conservation District notification per Chapter 102.
Date of approval ____________
NPDES Permit # _____________ for earth disturbances 1 acre or more,
Date of approval ____________
Driveway Permit, Penn DOT # _____________ or Local # __________
Date of approval ____________
Public water tap, Permit # _____________
Date of approval ____________
Public sewer tap, Permit # _____________
Date of approval ____________
Historical Architectural Review Board,
.
Date of approval ____________
Check here for Special conditions
Zoning, Permit # _________________
Date of approval ____________
Check here for Special conditions
Other; sluce pipe, road alteration, etc.
.
Date of approval ____________
Check here for Special conditions
Floodplain mapping ____________
Project may contain flood plain.
Date of review
________________
Municipal setback clearances,
.
Date of approval ____________
Check here for Special conditions
Aviation Flight Path or Airport Impact Possible
Date of approval ____________
Check here for FAA or Pa DOT approval
Extra Pages attached to describe special conditions or circumstance.
How many extra pages are attached? _________
_________________________________________________
_______________
{SEAL}
Approved - Municipal Official’s Signature & Title
Date
After completion of this checklist you may apply for a building permit by providing this checklist, the appropriate permit application and
supporting documents to Pennsylvania Municipal Code Alliance for processing. {Rev. 9.0 4/14/15}
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