1 & 2 Family Dwelling Residential Permit Application Form printable pdf download

City of Lancaster, PA.

120 North Duke Street P.O. Box 1599 Lancaster, PA 17608

8:30 AM - 5:00 PM Permits and scheduling - 717-291-4724

1 & 2 Family Dwelling Residential Permit Application

APPLICANT/CONTACT PERSON: _________________________________________________________

COMPANY COMPLETING APPLICATION: _________________________________________________

Address (include zip code): ___________________________________________________________________

__________________________________________________________________________________________

Telephone Numbers:

Home/Office # _________________

Cell# _____________

Fax: ______________

Email Address: _____________________________________________________________________________

Is this property located within a floodplain area?

YES

A local Regulatory Floodplain Elevation Certificate is required for any project located within a floodplain area.

Are windows, doors or exterior materials being changed or updated at this property?

YES

Do Zoning Hearing Board/Planning Commission stipulations apply to this project/property?

YES

Applicant Signature: ________________________________________________________________________

Owner

Agent (Contractor) for owner or tenant

PROPERTY OWNER: __________________________________________________

SAME AS ABOVE

Address: __________________________________________________________________________________

Telephone Numbers:

Home/Office # _________________

Cell# _____________

Fax: ______________

Project Location/Street Address: _____________________________________________________________

Is Property Condemned:

Yes

Project Description: ________________________________________________________________________

__________________________________________________________________________________________

Project Cost (fair market labor & material): All trades and project components must be included: $ _______________

MUST PROVIDE COPY OF CONTRACT/PROPOSAL OR ESTIMATE WITH APPLICATION

General Contractor Information: Name: ______________________________________

SAME AS ABOVE

Contractor complete address (include zip code): ___________________________________________________

Telephone Numbers:

Home/Office # _________________

Cell# _____________

Fax: ______________

Home Improvement Contractor’s Registration Number if applicable: __________________________________

Workers’ Compensation Insurance:

YES

NO If no, contractor must provide a notarized exemption form.

Contractor must provide a Certificate of Insurance listing the City of Lancaster as the certificate holder.

Notice to taxpayer. By Ordinance No. 15-2009, you may be entitled to exemption from tax on your contemplated improvements by

reassessment. A LERTA application for exemption may be secured from the Bureau of Code Compliance and Inspections and must

be submitted with permit application.

Bureau reviews and sign off’s

Date/Signature

Planning ……………………More Info needed [ ]

_________/____________________________________

Storm Water..….……………More Info needed [ ]

_________/____________________________________

Zoning ……………………...More Info needed [ ]

_________/____________________________________

HARB (Historical District)…More Info needed [ ]

_________/____________________________________

Health Department …………More Info needed [ ]

_________/____________________________________

Public Works Official………More Info needed [ ]

_________/____________________________________

Public Water and Sewer Line Connections require separate approvals.

OFFICE USE ONLY

Code Compliance Office Review/Approval: _______________________________ Date: _______________

Permit # ________________

Permit Fee:

$___________ State: $4.00 Total Fee: $___________

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1 & 2 Family Dwelling Residential Permit Application Form

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