East Brunswick Township Uniform Construction Code Building Permit Application Location of proposed work or improvement: Street Address: Lot No.: Tax Parcel No.: Owner: Phone No.: City: State: Zip: Principal Contractor: Phone No.: City: State: Zip: Fax No.: E-mail: Designer: Phone No.: City: State: Zip: Fax No.: E-mail: Type of work of improvement (check one): New Building Addition Alteration Repair Swimming Pool Demolition Deck Foundation Only Change of Use Plumbing Mechanical Electrical Describe the proposed work: Square footage of construction: Estimated cost of construction: Note: Construction value may be based on stated square footage value or the ICC valuation charts as per the type of construction, if a dispute arises Description of building use: Residential One-Family dwelling Two-Family dwelling Building/Site Characteristics: Non-Residential Specific use: Use group: Change in use: Yes No If Yes Indicate former: Maximum occupant load: Maximum live load: Number of residential dwelling units: Existing Proposed Mechanical: Indicate type of heating/ventilating/air conditioning (electric, gas, oil, etc.) Water service: Public Private Sewer service: Public Private (permit no.) Does or will your building contain any of the following: Fireplace(s) Number Type of Fuel Type of vent Elevator/Escalator/Lifts/Moving walks: Yes No Type Sprinkler system Yes No Pressure vessels Yes No Refrigeration system Yes No
Building Dimensions: Existing building area: Sq. ft. Number of stories: Proposed building area: Sq. ft. Height of structure above grade: Ft. Total building area: Sq. ft. Unfinished basement: Sq. ft. Finished basement: Sq. ft. Garage: Sq. ft. Porches and Decks: Sq. ft. Floodplain Is the site located within an identified flood hazard area? Yes No Will any portion of the flood hazard area be developed? Yes No Owner/Agent shall verify that any proposed construction and/or development activity complies with the requirements of the National Flood Insurance Program and the Pennsylvania Flood Plain Management Act (166-1978), specifically Section 60.3. Lowest Floor Level: (i.e. basement, ground, etc.) Stormwater Management (East Brunswick Township Ordinance 2008-4) Is a Stormwater Management Application required for this project? Yes No If so, has the SWM Application and Plan been approved by the Township? Yes No Historic District Is the site located within a Historic District? Yes No If construction is proposed within a Historic District, the Borough may require a certificate of appropriateness. The applicant certifies that all information on this application is correct and the work will be completed in accordance with the approved construction documents and PA Act 45 (Uniform Construction Code) and any additional approved building code requirements adopted by the Borough. The property owner and applicant assume the responsibility of locating all property lines, setback lines, easements, rights-of-ways, flood areas, etc. Issuance of a permit and approval of construction documents shall not be construed as authority to violate, cancel or set aside any provision of the codes or ordinances of the Borough or any other governing body with jurisdiction. The applicant certifies that he/she understands all the applicable codes, ordinances and regulations. Application for a permit shall be made by the owner or lessee of the building or structure, or agent of either or by the registered design professional employed in connection with the proposed work. I certify that the code administrator or the code administrator s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. Signature of Owner or Agent Print Name of Owner or Agent Date: Permit No. Date Zoning approved: Permit Fee: Directions to the site: For Township Use Only Date Approved/Denied: Signature of Plan Reviewer If Denied, reason:
East Brunswick Township Uniform Construction Code Plumbing Permit Application Location of proposed work or improvement: Street Address: Tax Parcel #: Lot #: Owner: Phone #: Principal Contractor: Phone: Designer: Phone: Mailing Address: City: State: Zip: Type of Work or Improvement (check one): New Building Addition Alteration Repair Demolition Describe the Proposed Work: Number of Fixture Units Estimated Cost of Construction Number and Size of Soil Stacks Type of Sewage Disposal Size of Building Drain Size of Building Sewer Type of Septic Tank and Capacity (give dimensions and number of tanks) Type of Final Disposal 1.Tile Field 2.Seepage Pit 3.Other Type and Number of Fixtures, Drain and Trap Size: Basement (include stub up for future) Type(s) Size(s) 1 st Floor Type(s) Size(s) 2 nd Floor Type(s) Size(s) 3 rd Floor Type(s) Size(s) Additional fixture listing
Description of Building Use (check one): Residential One-Family Dwelling Two-Family Dwelling Non-Residential Specific Use: Use Group: Change in Use: Yes No If Yes Indicate Former The applicant certifies that all information on this application is correct and the work will be completed in accordance with the approved construction documents and PA Act 45 ( Uniform Construction Code) and any additional approved building code requirements adopted by the municipality. The property owner and applicant assume the responsibility of locating all property lines, setback lines, easements, rights-of-way, flood areas, etc. Issuance of a permit and approval of construction documents shall not be construed as authority to violate, cancel or set aside any provision of the codes or ordinances of the Municipality or any other governing body. The applicant certifies that he/she understands all the applicable codes, ordinances and regulations. Application for a permit shall be made by a Registered Master Plumber or by the Registered Design Professional employed in connection with the proposed work. I certify that the code administrator or the code administrator s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. Signature of Owner or Agent Print Name of Owner or Agent Date: Permit # Permit Fee: Directions to Site:
East Brunswick Township Uniform Construction Code Electrical Permit Application Location of proposed work or improvement: Street Address: Tax Parcel #: Lot #: Owner: Phone #: Principal Contractor: Phone: Designer: Phone: Mailing Address: City: State: Zip: Type of Work or Improvement (check one): New Building Addition Alteration Repair Demolition Describe the Proposed Work: Service Size: Amps Service Conductor Size: Number of Circuits: Service Type: underground overhead Utility Company: Job Number: *Note* Must contact the electric company to ascertain proper location of service and meter panel. Failure to do so may delay power hook-up. Number Receptacles: Conductor Size: Number Switches: Conductor Size: Cook Top Voltage: Conductor Size: Oven/Range Voltage: Conductor Size: Dryer Conductor Size: Conductor Size: Earth Grounding Type and Material (i.e. grounding rod, ground ring, concrete encased electrode, etc.) Grounding electrode size: Back up Generator: Yes No If Yes, Size and Voltage Output
Description of Building Use (check one): Residential One-Family Dwelling Two-Family Dwelling Non-Residential Specific Use: Use Group: Change in Use: Yes No If Yes Indicate Former The applicant certifies that all information on this application is correct and the work will be completed in accordance with the approved construction documents and PA Act 45 ( Uniform Construction Code) and any additional approved building code requirements adopted by the municipality. Issuance of a permit and approval of construction documents shall not be construed as authority to violate, cancel or set aside any provision of the codes or ordinances of the Municipality or any other governing body. The applicant certifies that he/she understands all the applicable codes, ordinances and regulations. Application for a permit shall be made by the property owner or agent or by the Registered Design Professional employed in connection with the proposed work. I certify that the code administrator or the code administrator s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. Signature of Owner or Agent Print Name of Owner or Agent Date: Directions to Site: Township Use Only Date Approved/Denied Permit No. Permit Fee: Plan review performed by: Signature Print Name If denied, state reason:
East Brunswick Township Uniform Construction Code HVAC and Fuel Tank Permit Application Location of proposed work or improvement: Street Address: Tax Parcel #: Lot #: Owner: Phone #: Principal Contractor: Phone: Designer: Phone: Mailing Address: City: State: Zip: Type of Work or Improvement (check one): New Building Addition Alteration Repair Demolition Describe the Proposed Work: Heating Type of Fuel BTU: Input Mfg: Output Installation Cost Air Conditioning BTU Mfg: Installation Cost Fuel Tank Fuel Type Capacity of Tank Installation Cost
Will the new heater be vented to the existing chimney? YES ( ) NO ( ) If not, how will the new heater be vented? Has the existing chimney been inspected? YES ( ) NO ( ) If so, by whom, and what are his/her qualifications? (Name, address and phone number) Was the chimney approved? YES ( ) NO ( ) If not, what repairs were required? What is the condition of the chimney? How many appliances will be vented into the chimney? Will the heater in an enclosed or insulated space? YES ( ) NO ( ) How will adequate combustion air be provided? Description of Building Use (check one): Residential One-Family Dwelling Two-Family Dwelling Non-Residential Specific Use: Use Group: Change in Use: Yes No If Yes Indicate Former The applicant certifies that all information on this application is correct and the work will be completed in accordance with the approved construction documents and PA Act 45 (Uniform Construction Code) and any additional approved building code requirements adopted by the municipality. Issuance of a permit and approval of construction documents shall not be construed as authority to violate, cancel or set aside any provision of the codes or ordinances of the Municipality or any other governing body. The applicant certifies that he/she understands all the applicable codes, ordinances and regulations. Application for a permit shall be made by the property owner or agent or by the Registered Design Professional employed in connection with the proposed work. I certify that the code administrator or the code administrator s authorized representative shall have the authority to enter areas covered by such permit at any reasonable hour to enforce the provisions of the code(s) applicable to such permit. Signature of Owner or Agent Print Name of Owner or Agent Date: Permit # Permit Fee: Directions to Site:
East Brunswick Township Application for Contractor Registration Date: Registration No: FOR THE ISSUE OR RENEWAL OF REGISTRATION TO ENGAGE IN AND CARRY ON THE BUSINESS OF: O GENERAL CONTRACTOR O ELECTRICAL CONTRACTOR O PLUMBING CONTRACTOR O HVAC CONTRACTOR O ROOFING CONTRACTOR (PLEASE PRINT) Name of Contractor: Name of Company: Address of Company: Phone Number: Fax Number: Registration Fee: $50.00 Make Check Payable To: East Brunswick Township 55 West Catawissa Street New Ringgold, PA 17960 IMPORTANT: ENCLOSE A CERTIFICATE OF INSURANCE, SHOWING YOUR LIABILITY & WORKERS COMP LIMITS, WHICH WILL COVER YOU/YOUR COMPANY FOR THE ENTIRE YEAR. CERTIFICATE MUST READ EAST BRUNSWICK TOWNSHIP WITH ADDRESS. *****PLEASE DO NOT FAX CERTIFICATE OF INSURANCE***** Copy of a license card from another Township or borough. List of 3 job references is required for all contractors. Please include addresses and phone numbers for all references. Signature of Applicant: Date:
COMMONWEALTH OF PENNSYLVANIA COUNTY OF Affidavit BEFORE ME,, A NOTARY PUBLIC, THE UNDERSIGNED OFFICER, THIS DAY PERSONALLY APPEARED (NAME AND ADDRESS) TO ME KNOWN (OR SATISFACTORILY PROVEN,) WHO BEING DULY SWORN ACCORDING TO LAW, DESPOSES AND SAYS: (STATEMENT STARTS HERE) Workers compensation Insurance Coverage Information (Attach to building permit application) A. Applicant Name: Tax ID # or Social Security #: B. The Applicant is a contractor within the meaning of the Pennsylvania Workers Compensation Law: ( ) YES (complete Section C ) ( ) NO (complete Section D ) C. Insurance information: APPLICANT IS A QUALIFIED SELF-INSURER FOR WORKMEN S COMPENSATION. ( ) Certificate of Insurance is attached Name of Workers Compensation Insurer: Workers Compensation Insurance Policy No: Policy Expiration Date: The undersigned deposes and says that the information set forth above is true and correct to the best of the knowledge, information and belief of the undersigned and that such is given subject to the penalties of 1B Penn. C.S., Section 4904, relating to unsworn falsification to the authorities. **See Notary Information Below Applicant Signature D. Exemption: COMPLETE THIS SECTION IF THE APPLICANT IS A CONTRACTOR CLAIMING EXEMPTION FROM PROVIDING WORKERS COMPENSATION INSURANCE: The undersigned swears or affirms that he/she is not required to provide workers compensation insurance for one of the following reasons: ( ) Contractor with no employees. Contractor is prohibited by law from employing individuals to perform any work pursuant to this building permit unless contractor provides proof of insurance as required by section C above. ( ) Religious exemption under Workers Compensation Law. Applicant Signature NOTARY INFORMATION: Subscribed and sworn before me This day of, 20. Applicant Address Signature of Notary: (SEAL)
(This Form Requires a Notary Seal) East BrunswickTownship Affidavit of Exemption The undersigned affirms that he/she is not required to provide workers compensation insurance under the provisions of Pennsylvania s Workers Compensation Law for one of the following reasons, as indicated: Property owner performing own work. If property owner does hire a contractor to perform any work pursuant to building permit, the contractor must provide proof of workers compensation insurance to the municipality. Homeowner assumes liability for contractor compliance with this requirement. Contractor has no employees. Contractor prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of insurance to the municipality. Religious exemption under the Workers Compensation Law. All employees of contractor are exempt from workers compensation insurance. (Attach copies of religious exemption letters for all employees). Signature of Applicant County of Municipality of Subscribed, sworn to and acknowledged before me by the above this day of, 20 SEAL Notary Public