INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT

STUDY PARTICIPANT INITIALS HOSPITAL FOR SPECIAL SURGERY 535
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INITIALS:

INITIALS: DATE: FEE: PERMIT NO.

IF REQUIRED, DID APPLICANT RECEIVE APPROVAL FROM: ZONING? [ ] YES [ ] NO [ ] N/A

HEALTH? [ ] YES [ ] NO [ ] N/A

**FOR OFFICE USE ONLY**

INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT

BINITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT UILDING/ALTERATION PERMIT APPLICATION

CITY OF ALLENTOWN

**PLEASE PRINT CLEARLY USING BLACK INK**

All work materials and construction will be in accordance with the rules and regulations of the Building code of the city of Allentown

INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT

LOCATION OF BUILDING:

INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT Street City State Zip

PRESENT USE OF BUILDING: [ ] Single Family [ ] Apartment [ ] Office [ ] Retail

[ ] Garage [ ] Warehouse [ ] Other

If other, please specify:

DESCRIPTION OF PROPOSED ALTERATIONS: [ ] Interior [ ] Exterior

[ ] Roof # of roofing squares ______________ [ ] New Construction [ ] Addition

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

EINITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT STIMATED COST FOR ALTERATIONS: $

ADDITIONAL PERMITS REQUIRED FOR JOB COMPLETION:

[ ] Electrical [ ] Plumbing [ ] Health [ ] Sewer [ ] Zoning [ ] Engineering

[ ] Fire [ ] Mechanical [ ] Heating [ ] N/A

IS THE ABOVE REFERENCED STRUCTURE LOCATED IN A FLOOD PLAIN? [ ] Yes [ ] No

If yes, a Real Estate appraisal to provide a market value is required


DOES APPLICANT HOLD A CURRENT BUSINESS LICENSE? [ ] YES [ ] NO [ ] N/A BL#:

DOES APPLICANT HOLD CURRENT INSURANCE? [ ] YES [ ] NO [ ] N/A

INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT

PROPERTY OWNER NAME (Individual or Business):

OWNER MAILING ADDRESS:

Street City State Zip

OWNER PHONE NO.

CONTRACTOR NAME:

CONTRACTOR ADDRESS:

Street City State Zip

CONTRACTOR PHONE NO. _____________________ STATE CONTRACTOR LICENSE NO. ___________________________

Application is hereby made for a permit to build or alter a structure on the premises described herewith. The information which follows, together with the required additional information, is made part of the application by the undersigned. It is understood and agreed by this applicant that any error, misstatement or misrepresentation of material fact, either with or without intention on the part of this applicant, such as might or would operate to cause a refusal of this application, or any change made subsequent to the issuance of the permit, without approval of the Inspections Division shall constitute sufficient grounds for the revocation of this permit, and/or prosecution.


APPLICANT SIGNATURE: PLEASE PRINT NAME:

**This Side for Inspector**

Building Inspection Log

ZN Permit No. _______________

Permit No. ____________ ___

Address: ZN APP No. ______ _________

Street City State Zip

INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT INITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT

DINITIALS DATE FEE PERMIT NO IF REQUIRED DID APPLICANT ATE CODE: BLDG TYPE: USE: BY:


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Tags: applicant receive, prosecution. applicant, permit, initials, applicant, required