Change Of Use And/or Occupancy Form - East Goshen Township (Page 2 of 3) in pdf

EAST GOSHEN TOWNSHIP

CHANGE OF USE AND/OR OCCUPANCY

PAGE 2

5. RENTAL INFORMATION:

 Residential

 Non-Residential

 Condominium

 Single-Family Dwelling

 Apartment Complex

CONTACT INFORMATION:

____________________________  N/A

Move In Date: _______________

Complex Name:

________________________________________________________

Contact Person:

Property Owner, Leasing Agent Responsible Party for the Rental

Contact Phone:

___________________________

__________________________

Daytime

Cell # or Alternate #

Fax: __________________________ E-Mail Address: _____________________________________________

As per Township Ordinance No. 109 certain property owners are required to file Rental Occupancy Reports on a semi-annual basis.

Please be sure to obtain this form which can be found on the Township website with the related Ordinance.

__________________________________________________________________________________________________

6. NEW CHANGE OF USE:

Describe the current use: __________________________________________________________________________

________________________________________________________________________________________________

Describe proposed use: __________________________________________________________________________

________________________________________________________________________________________________

Will the change of use and occupancy require additons/alterations/renovations/fit-out?  Yes  No

If yes, have you filed the appropriate permit applications?

 Yes  No

Will the current use be discontinued?

 Yes

 No

Will the number of Employees:

 Increase

 Decrease  Stay the same

By how many? _______

__________________________________________________________________________________________________

7. SECTION B - CHANGE OF OCCUPANCY:

Date change is effective: __________________

This property is zoned:

 Commercial  Business Park

 Industrial

Reason for change:

 Sale

 Lease

Realtor’s Name:

____________________________________

Phone Number: ____________________

Address:

_________________________________________________________________________

__________________________________________________________________________________________________

8. CERTIFICATION OF SUBMISSION:

This application has been examined and reviewed by me and to my knowledge and belief is true, correct and complete.

I am the:  property owner;  equitable owner or;  authorized agent permitted by the property owner

Print Name: _________________________________

Signature _______________________________

__________________________________________________________________________________________________

*** FOR OFFICIAL USE ONLY BELOW ***

Sewer/Trash: ____________ Date: ______________

Fee Amt Required: ___________

Acct #: ____________

Use approved:

 Yes  No  N/A

Inspection Required:  Yes  No

CO Issued:

 Yes  No  N/A

Fee Paid:

 Yes  No

Resale/Rental/CO #: _________________

Inspection Date : _____________________ (if scheduled at application submission)

Comments: _________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

F:\Data\Shared Data\Code Dept\Application & Forms\Current Forms and Applications\Change of Use and or Occupancy Multi Use App 07012015.doc

Change Of Use And/or Occupancy Form - East Goshen Township Page 2

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