Form Center

2. TOWNSHIP*
3. County*
5. Township Address*
7. Date*
   Date
9. Site Address*

   (Where work is to be done)

11. City
12. State
13. Zip Code
15. Application is hereby made by:
17. First Name*
18. Last Name*
20. Phone Number*
21. Email Address*
23. Address of Applicant*
25. City
26. State
27. Zip Code
29. for permission to: *
31. Under and subject to all the conditions, restrictions, and regulations prescribed by the Township and on the general provisions and specifications, a true copy whereof is attached and made a part hereof, with the same force and effect as if written printed herein and under and subject to the special conditions, restrictions, and regulations hereinafter set forth.
35. Data Applicable to this Application
37. GENERAL
39. Approx Date Work Will be Started*
    Approx Date Work Will be Started
40. Approx Date Work Will be Completed*
    Approx Date Work Will be Completed
42. Poles and Tower

    Number of Poles to be Erected:

44. Pipe Lines and Conduits
    -- Select One --willwill not

    The improved surface of the road (will) / (will not) be opened.

    Do not answer if this does not apply to your application.

45. Pipe Lines and Conduits Cont.

    Approximate area of openings in improved surface: _____ square yards. 

    Do not answer if this does not apply to your application. 

47. Pipelines and Conduits Cont.

    Approximate area of openings on unimproved part: _____ square yards.

    Do not answer if this does not apply to your application.

48. Pipe Lines and Conduits Cont.

    Length of trench along the road: ______ feet.

    Do not answer if this does not apply to your application.

50. Pipe Lines and Conduits Cont.

    Depth of trench below surface: _______ inches.

    Do not answer if this does not apply to your application. 

52. Type of Applicant*
    -- Select One --IndividualPartnershipCorporation

    The applicant is (an individual) / (a partnership) / (a corporation incorporated under the law of Pennsylvania)  

54. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
56. Electronic Signature
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field