Application For Temporary Occupancy Permit

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A
T
O
P
PPLICATION FOR
EMPORARY
CCUPANCY
ERMIT
PLEASE PRINT- APPLICANT TO COMPLETE THIS SIDE OF APPLICATION ONLY.
PROPERTY & OWNER INFORMATION
Property Address: ____________________________________________________________________
Date: ________________
Space Number: _____________
Parcel ID: _________ - _____ - _________
Ward: ________________
Owners Name: _______________________________________________________________________________________________
Address: ___________________________________________________________________
Phone: (
) _______________
City: __________________________________ State:______ Zip Code: _____________
Fax:
(
) _______________
TENANT / LESSEE / BUSINESS INFORMATION
Name: _____________________________________________________________________________________________________
Address: ______________________________________________________________________ Phone: (
) _______________
City: __________________________________ State:______ Zip Code: _____________
Fax:
(
) _______________
TEMPORARY OCCUPANCY REQUESTED (Describe in detail)
Partial occupancy as follows:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
REASON FOR REQUEST
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
REMAINING WORK TO BE COMPLETED
Describe in detail the remaining work to be completed including all interior, exterior, outside parking, landscaping or any other work.
(Attach separate page if necessary)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ESTIMATED DATES OF COMPLETION
INTERIOR WORK:
____________________ 20______
EXTERIOR WORK:
____________________ 20______
LANDSCAPING AND PARKING AREA IMPROVEMENTS:
____________________ 20______
TOTAL WORK COMPLETED AS ORIGINALLY APPLIED FOR:
____________________ 20______
STATEMENT OF TRUTH
COMMONWEALTH OF PENNSYLVANIA COUNTY OF ALLEGHENY
Deponent, being duly sworn, says they are the:
Owner of record of the property for which this application is made, and that all the statements and data furnished with this
application are true and correct.
Authorized agent for the owner of record of the property for which this application is made and as such has express authority to bind
such owner to all terms and conditions of any occupancy permit issued pursuant to this application, and that all statements and data
furnished with this application are true and correct.
Sworn to and subscribed before me this ______ day of _______________________ 20 ______.
_________________________________
_________________________________
__________________________________
Notary Public
Applicant (signature)
Applicant (printed)
NOTICE
THIS IS NOT A PERMIT. BEFORE THE SUBJECT PROPERTY CAN BE USED AS APPLIED FOR, A TEMPORARY CERTIFICATE
OF OCCUPANCY (VALID FOR THE INTERIM PERIOD APPROVED) AND/OR A FINAL OCCUPANCY PERMIT (UPON
EXPIRATION OF THE TEMPORARY CERTIFICATE) MUST BE SECURED FROM THE HOMESTEAD BOROUGH BUILDING
INSPECTION DEPARTMENT.
THE APPROVAL OF THIS APPLICATION BY THE HOMESTEAD BOROUGH ZONING OFFICER DOES NOT MEAN THE
PROPOSED USE COMPLIES WITH ANY ORDINANCE, BUILDING CODE OR LAW; OTHER THAN THE HOMESTEAD BOROUGH
ZONING ORDINANCE.

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