Driveway Permit Application

Permit Number*

Name*

First Last

Phone*

Address of Applicant*

Street Address Address Line 2 City State ZIP Code

Address of Property to be Improved*

Street Address Address Line 2 City State ZIP Code

Contractor*

Application is made to:*

Construct a new driveway
Alter an existing driveway
Utility installation
Other

What is other?

Date Work Schedule to Begin*

Date Work Scheduled to be Completed*

Intended Use*

Residential
Commercial
Industrial

For Driveways (6-9): Applicant to place a stake at the center line of the proposed driveway

Road Name and No.

Name of Nearest Intersection

Distance to Nearest Intersection in Feet

For the purpose of measuring sight distance, the drivers' eye height shall be 3.50 feet above the proposed access surface and highway pavement surface and the vehicles' height shall be 4.25 feet above the proposed access surface and highway payment surface.

Posted Speed Limit

Roadway Sight Distance (Right) in Feet

Roadway Sight Distance (Left) in Feet

Driveway Radius (Left) in Feet

Driveway Radius (Right) in Feet

Radius (R) of both driveway curves must be at least five feet for cars.

Completed Sketch (if required)

For Utility Installaion

:

Length of Excavation

Depth of Excavation

Location (distance to nearest intersection)

From begin	From end

Sketch or Engineering Plan (if required)

Bond (if required)

Certificate of Insurance

Total Fees

Additional Fees

Issuing Permit	Township Inspection Fee

Applicant shall place a stake at the desired location which shall coincide with submitted sketch.

Permission is hereby granted to the construct driveway or utility station from the township and stated in number three (3) as per specifications of Township Roadmaster hereon. (Description of Work)

Under and subject to all the conditions, restrictions, and regulations prescribed by the Township Supervisors on the reverse, a true copy is attached and made a part of, with the same force and effect as if written or printed herein and subject to the special conditions, restrictions, and regulations hereinafter forth.

Compliance Agreement*

I hearby agree to comply with all relevant Ordinances of the Township (including this Ordinance) and statues of the Commonwealth of Pennsylvania, together with all relevant resolutions and regulations promulgated under either.

Protection Agreement*

I agree to defend, protect and save harmless the Township and its officers, agents and employees from any and all loss and liability rising out of any work to be performed pursuant to this permit, and shall fully idemnify the Township, its officers, agents and employees.

This applications hall be considered as an application only - it may be considered a township road occupancy permit only at the time the specification of the Township Roadmaster is entered heron and a complete copy(s) furnished to the applicant.

All work under this permit is to be completed on or before six (6) months from the date of permit issuance. The Township Supervisors, may at any time revoke and annul this permit for non-performance of, or non-compliance with any of the conditions, restrictions, and regulations hereof.

Signature of Applicant*

For Driveways (6-9): Applicant to place a stake at the center line of the proposed driveway

For Driveways (6-9): Applicant to place a stake at the center line of the proposed driveway

For Utility Installaion

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