Form Ucc-3 - 2007 Application For Building Permit Page 3
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1
2
3File #:
________________
Permit #:
________________
Date:
________________
S4
Owner
Owner Name
______________________________________________
Information
Street Address
______________________________________________
City
____________________
State __________
Zip Code __________
Phone Number _____________________________
Deferred
If you are not submitting plans and other documentation for any of the items listed below with
Submissions
this application, check the appropriate box below and indicate this on the first page of each
building plan set.
Fire Alarm System
Truss Shop Drawings (Certified)
Sprinkler System
Fees:
List total sq. ft. of floor area: ___________
List estimated construction cost: ______________
If new building or addition:
pay $100.00 base fee $_______________
Plus, pay $.20 multiplied by total sq. ft. of floor area $_______________
If new structure or facility (other than building):
pay $300.00 $_______________
If alteration or renovation of existing building:
pay $100.00 base fee $_______________
Plus, pay $20.00 per each $1000 of est. construction cost $_______________
If accessibility only review:
pay $200.00 $_______________
If phased approval:
pay $300.00 $_______________
If revision of approved plans or partial occupancy
pay $300.00 $_______________
request:
0.00
TOTAL FEES OWED $_______________
Make check or money order payable to Commonwealth of Pennsylvania.
Applicant’s Certification:
As the owner or the authorized agent of the project for which this application is filed, I certify that:
1.
The estimated construction cost and all other information provided as part of this application for a
building permit is correct.
2.
The building or structure described in this application will not be occupied until all known code
violations are corrected and a Certificate of Occupancy has been received from the Department of
Labor & Industry.
3.
This project will be constructed in accordance with the approved drawings and specifications (including
any required non-design changes) and the Uniform Construction Code standards as specified in 34 PA
Code Chapters 401-405.
4.
Any changes to the approved documents will be filed with the Department of Labor & Industry.
5.
If the licensed architect or engineer in responsible charge of this construction should change, written
notice of the change will be provided to the Department of Labor & Industry.
6.
When required, up to 20% of the total cost of any work performed on an area of primary function in an
existing building will be expended to provide an accessible route to the area of primary function.
7.
No error or omission in either the drawings and specifications or application, whether approved or not,
shall permit or relieve me from constructing the work in any manner other than provided for in 34 PA
Code Chapters 401-405.
Applicant Name
______________________________________________
Street Address
______________________________________________
City
____________________
State __________
Zip Code __________
Phone Number
____________________________
Applicant
Signature
_______________________________
Date __________________
UCC-3 REV 1-07 (Page 3)
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