LEHIGH ENGINEERING, LLC UCC PERMIT APPLICATION ver.—1/21
200 Mahantongo St., P.O. Box 1200 Pottsville, PA 17901
Ph. 570.628.2300
Building Permit ____________________________ Parcel Number ________________________________
Municipality _________________________________ County ___________________________
Construction Site Location ________________________________________________________ Date Received _____________
Owner ____________________________________________ Applicant/Tenant _____________________________________
Address ___________________________________________ Address ____________________________________________
State ______ Zip ___________ Phone #_________________ State _____ Zip _________ Phone #___________________
Describe Proposed Work in Detail:____________________________________________________________________
SECTION 1— BUILDING PERMIT
Contractor _________________________________________ PA HIC #
(if owner put same as above)
Address ____________________________________________ *Total Estimated Cost $ __________________________
City ____________________ State ______ Zip ____________ Total SQ FT __________ # of Stories _______ Height ______
Phone ___________________ Cell__________________ ____ Description of Work: _________________________________
Federal Employee # __________________________________ ________ __________________________ _________
[Certification of Insurance for Workers Compensation needed or sig n exemption form] Addition ( ) Deck ( ) Roof ( ) Pool ( ) Sign ( )
Additional Information: __________________________________________________________________________________
( Official Use ) State Classification: Use Group _______ Construction Class _______
New Residential _____ Other Residential _____ New Commercial _____ Other Commercial ____
__
Contractor _____________________________________ ____
(if owner put same as above)
Address ____________________________________________
City ____________________ State ______ Zip ____________
Phone ___________________ Cell__________________ ____
Federal Employee # __________________________________
[Certification of Insurance for Workers Compensation needed or sig n exemption form]
Estimate Total Costs for This Work $_______ _______
(Official Use ) — State Classification:
New Residential _____ Other Residential ____
New Commercial _____ Other Commercial ____
SECTION 2— ELECTRICAL PERMIT Utility #__________________
Technical Site Data
No. Size Fixture / Equip. No. Size Fixture / Equip.
Lighting Fixture Range
Receptacles Dishwasher
Switches Garbage Disp.
Detectors HVAC
Motor-Fraction. Emergency &
Comm. Devices ________ Exit Lights
Alarm Dev./Sys. Heater
Pool Bonding Central AC Unit
_________ Service Signs
_________ Sub-Panels Survey Fee
Others:
Contractor _____________________________________ ____
(if owner put same as above)
Address ____________________________________________
City ____________________ State ______ Zip ____________
Phone ___________________ Cell__________________ ____
Federal Employee # __________________________________
[Certification of Insurance for Workers Compensation needed or sig n exemption form]
Estimate Total Costs for This Work $_______ _______
(Official Use ) — State Classification:
New Residential _____ Other Residential _____
New Commercial _____ Other Commercial _____
SECTION 3 — MECHANICAL / PLUMBING PERMIT
Technical Site Data
No. Size Fixture / Equip. No. Size Fixture / Equip.
Water Closet Boiler / Furnace
Urinal / Bidet Sewer Lat/Conn
Bathtub Backflow Prev.
Lavatory HVAC
Shower Kitchen Hood &
Sink Exhaust System
Dishwasher Refrig. Units
Washing Mach. Heat Pumps
Hose Bib Fire Dampers
Water Heater Water Connect.
Others:
