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Alarm System Application Form - East Goshen Township

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EAST GOSHEN TOWNSHIP

1580 Paoli Pike, West Chester, PA 19380

Phone: (610) 692‐7171 Fax: (610) 692‐8950

ALARM SYSTEM APPLICATION

In accordance with Ordinance No. 129‐J‐09 Adopted 10‐06‐09

Date: ________________ Please check: NEW REPLACEMENT COMMERCIAL RESIDENTIAL

5 3

PROPERTY LOCATION TAX PARCEL NUMBER:

‐ __ __ __ ‐ __ __ __ __ . __ __ __ __

(Where alarm system is to be installed)

NAME: ________________________________________________

ADDRESS: ________________________________________________

CITY: ____________________________ STATE: _____ ZIP: ___________

PHONE: __________________________ PHONE: __________________________

PROPERTY OWNER INFORMATION

NAME: ________________________________________________

ADDRESS: ________________________________________________

CITY: ____________________________ STATE: ________ ZIP: ___________

PHONE: __________________________ PHONE: __________________________

ALARM & INSTALLER INFORMATION

BURGLAR ALARM FIRE ALARM BOTH OTHER ____________________

MAKE & MODEL OF ALARM SYSTEM(S):___________________________________________

MANUFACTURER: ____________________________________________________________

INSTALLATION CONTRACTOR:

NAME: ________________________________________________

ADDRESS: ______________________________________________

CITY: ____________________________ STATE: ________ ZIP: ___________

PHONE: __________________________ PHONE: __________________________

PA STATE REGISTRATION NUMBER

_____________________

(Applies to Residential Installations‐ PA ACT 132)

TOWNSHIP CONTRACTOR NO. ________________

Applicant Signature ________________________________ Print Name: ______________________________

I hereby certify that the propose work is authorized by the owner of record and that I have been authorized by the owner to make this application as the

authorized agent and we agree to conform to all applicable laws of this jurisdiction. Construction shall comply with all applicable Township Codes

uilding/structure shall also comply with the American’s with Disabilities Act of 1990 where applicable. This application has been examined by me and to

my knowledge and belief is a true, correct and complete application.

Permit #: _______________

F:\Data\Shared Data\Code Dept\Application & Forms\Current Forms and Applications\TWP Alarm Application 3‐10‐2010.doc