M-945RC (9-14)
document “recording copy”
The applicant shall have this Document “Recording Copy” notarized in Block B and shall complete section one if an individual or section
A
two if a corporation.
The applicant shall return this Document “Recording Copy” signed (block A) and notarized - within 30 days to the appropriate
Engineering District Permit Office with a check to cover the cost of recording the permit. Checks shall be made payable to the “Recorder
of Deeds.”
ThE APPliCAnT AgREEs TO COmPly wiTh All ThE TERms AnD COnDiTiOns Of ThE PERmiT
ThE PERmiT will Run wiTh ThE lAnD
AnD BinDs ThE PERmiTTEE, his OR iTs hEiRs, AssignEEs OR suCCEssORs in inTEREsT.
DEED BOOk _______________
PAgE _____________
TAX PARCEl iD ________________________________________
The applicant is
an individual
a partnership
a corporation incorporated under the laws of _______________________
Date signed: ________________________________________
witness or Attest:
Print Applicant name: _________________________________
______________________________________________
signed By: __________________________________________
TiTlE Of signATORy
TiTlE Of signATORy
C
B
COmmOnwEAlTh Of PEnnsylvAniA
:ss:
COmmOnwEAlTh Of PEnnsylvAniA
:ss:
COunTy Of ___________________________________________ :
COunTy Of ___________________________________________ :
On _______________________________________ , before me, the
Permit number: __________________________________________
undersigned officer, personally appeared:
On ____________________________________________________
❏
(1) _________________________________________________
before me, the undersigned agent, personally appeared:
known to me (or satisfactorily proven) to be the person(s) whose
_______________________________________________________
name(s) is/are subscribed to the within instrument, and acknowl-
who acknowledged himself to be
edged that he/she/they executed the same for the purposes
therein contained.
_______________________________________________________
❏
(2) _________________________________________________
o f t h e D e p a r t m e n t o f Tr a n s p o r t a t i o n , a n a g e n c y o f t h e
Commonwealth, and that he as such agent, being authorized to do
who acknowledged to be the ____________________________
so, executed the foregoing instrument on behalf of said Department.
of __________________________________________________
in wiTnEss whEREOf, i have hereunto set my hand and
a corporation and that he as such officer, being authorized to
official seal.
do so, executed the foregoing instrument for the purposes therein
contained. By signing the name of the corporation by himself
as such officer.
in wiTnEss whEREOf, i have hereunto set my hand and official
seal.
(SEAL)
(SEAL)
D
i certify that, upon recording, the within instrument should be mailed to:
PEnnsylvAniA DEPARTmEnT Of TRAnsPORTATiOn
EnginEERing DisTRiCT ________________
_______________________________________________________
ATTEnTiOn: PERmiT OffiCE
,
agent for commonwealth of pennsylvania
department of transportation
E
COunTy RECORDER Of DEEDs
ACknOwlEDgEmEnT Of RECORDing