11/21  BOROUGHUSEONLY  ELIZABETETHVILLE BOROUGH  Permit # Date Issued Fees $  Dauphin County, Pennsylvania P.O. Box 578. 68 S. Moore St. Elizabethville, PA 17023  Ck# Permit Officer  Phone: (717)362-7945  Permit Officer (570)640-2661  Application for Administrative Building Permit Alli information must be printed and legible for permit acceptance.  General Information: Property Address: Tax Parcel IDI No., 26- Property Owner Name: Daytime Phone: ( Address: Applicant (If other than the owner): Address: Daytime Phone: (  (This information can be located on Property Tax Bill)  Email Address City. City. Email Address  State State  Zip Zip  Purpose of Permit Request: New Construction  New Single-Family Dwelling* New Commercial Building* Alterations or Change of Use Addition to existing structure* Accessory Structures  New semi-Detacned/Duplex  Porches/Deck"-covered/uncoyered  Other*  Change ofUse*. - Specify  angeCaport-Atacha" or Detached (please circle)  Accessory Residential Storage Structure** Accessory Commercial Storage Structure*  Solar or Wind Energy System* Swimming Pool* (above ground  In-ground  w/ a capacity of greater than 24" in water depth)  Other:  Project will require thei issuance ofa Uniform Construction Code (U.C.C.) Building Permit. ** Project may require the issuance ofa Uniform Construction Code (U.C.C.) Building Permit. Please verify with Borough Code Enforcement Officer.  Brief Description of Project: Total Value of Project:  Local Level Building Permit Fee Due $  ($10.00 base fee with an additional $2.50 per $1,000.00 oftotal value the project rounded to the nearest $1,000.00)  Page 1of3    11/21  Lot & Building Information: All requested information must be completed. Has there been any recent development on this Parcel of Record since January 10",2011? Yes  No  Ifyes, when and what was developed? Current use of the property: Residential  Commercial  Industrial  Total Lot Area: (Sq.Ft) CornerLot?. Yes Proposed Building Size: Coverage: (Includes AllI Impervious Surfaces) Existing Lot Coverage: Proposed Lot Coverage:  (Note: 1a acre equals 43,560 square feet)  No  (Sq. Ft.) Proposed Height:  Dimensions:  X  (Sq.Ft.) (Sq.Ft.)  % ofLot Area % ofLot Area  Proposed Setbacks: (Location of the proposed structure from the lot lines indicated in feet) Minimum Setbacks from the lot lines are as follows, Front- - 40 feet, Sides-1 15 feet, and Rear- - 40 feet.  Front Yard Additional Features  Left Side Yard  Right Side Yard  Rear Yard  Are there any easements or deed restrictions on your property? Yes (Please provide copy of Deed if possible)  No  Are there any environmentally sensitive features located on the property elmoswacylopan.  Yes  No  For changes to existing residential structures Number of bedrooms in structure  proposed  Sewage Disposal System: Public Sewer  On-Lot Septic Well  Other: Other:  Water Supply:  Public Water  Uniform Construction Code Building Permit  Does this project require al Pennsylvania Uniform Construction Code building permit? DYES Plot Plan:Required, Application will be declared incomplete without attaching Plot Plan)  NO  A plot plan showing all existing improvements and proposed construction, including driveways, walkways, storm water management features, easements, and utilities shall accompany this application. The plan shall include measurements of setbacks from all property lines and from the right-of-way ofa any road frontage on the property. Adjoining properties shall be labeled. Until such plan is submitted, this application shall not be considered complete and will not be processed. Ift the proposed is a Business, Industry, or a Change of Use of a new or existing building, please enclose a detailed description outlining the products sold, manufacturing process, services rendered, equipment to be used, floor areas of building, number of employees, and any other information that is necessary to thoroughly describe the proposed  operation.  Page 2of3    11/21  Administrative Building Permit Application Check List:  All Administrative Building Permit Applications shall be filed with Elizabethville Borough  P.O. Box 578, 68 S. Moore St. Elizabethville, PA 17023  All applicable information is included on the application in a legible form.  Attached a copy oft the plot plan showing: 1.All existing buildings a. Property lines b. Streams, ponds, or water courses C. Swales and ditches d. Roads or streets (public/private) e. Well, septic system; tank; drain field. 3.Location of any easement or right-of-ways. 4. Driveways and parking areas. driveway, erosion and sediment control plan)  2.Location oft the new improvement showing the distance from all the following features  Attached copies of any and all other permits that may be required for the project. (i.e., septic/sewer, Check or money order made payable to Elizabethville Borough for permit application fees. Verified that the proposed project DOES NOT require any stormwater features.  Signature:  Ihereby authorize the designated official to investigate, inspect, and examine the property set forth herein, including land and structures, to determine compliance with thel Elizabethville Borough Administrative Building Permit Ordinance andt to determine the accuracy of thes statements contained herein. Ia am aware that I cannot occupy the property for the purpose ofconducting the use set forth herein and cannot commence excavation or construction until an Administrative Building Permit has been issued by An Administrative Building Permit may be revoked ift the use and/or structure for which it has been issued violates any applicable Borough, County, State or Federal law, or regulation, including buti notl limited tot thel Elizabethville Borough. Administrative Building Permit Ordinance. This Permit may also be revoked if it has been issued in error, or if issuance was based upon any misrepresentations or errors contained in the application or otherwise made by the applicant. By signing this application, Icertify lacknowledge that the holder of an Administrative Building Permit is responsible to ensure compliance with all applicable Borough Ordinances, and at completion oft the work authorized by the permit/acknowledge that thel Borough requires that ai final inspection be performed by the Permit Officer before the structure and/or land which is authorized by this permit may be occupied. Please be advised that the Administrativel Building Permit fee: associated witht this applicationi is only fort the basici review andi issuance ofthe Administrative Buildingl Permit. The applicant will be financially responsible for any additional permits and/or approvals that may be required for the proposed project, such as, but not limited to, Subdivision and/or Land Development, Stormwater  Elizabethville Borough.  that all facts in the application and all accompanying documentation are true and correct.  Management and Borough Consultant's costs.  Printed Name Signature: Printed Name Signature:  Date:  (Owner)  Date:  (Applicant, if not the owner)  Page 3of3