Date

Firm Name

Phone #

Address

Fax #

Individual Proprietorship

Partnership

Corporation

General Liability Insurance Carrier

Policy #

Amount of Coverage

Workman's Comp Insurance Carrier

Policy Number

If no employees, check here

Earthwork

Electric

General Contractor

Concrete

Sprinkler

Landscaping

Hardscaping

HVAC

Plumbing

Paving

Home Improvements

Signage

Type of business

Type of work to be performed (Check all that apply)

I understand that Amity Township enforces the PA Uniform Construction Code as described in PA Act 45 and I agree to comply with the applicable building codes as stated on each building permit. I understand that some of the work I do requires various inspections that I must call to schedule, and the work must be approved prior to proceeding with subsequent work. I understand that if I perform earthwork with a disturbance of over 5,000 sq. ft., I must also apply to the Berks County Conservation District under Act 102 "Erosion and Sediment Control". I will call PA ONE CALL at 800-242-1776 BEFORE DIGGING.

A copy of your contractor's insurance certificate, naming Amity Township as additional insured, must also be submitted, along with a check for $50. License will be valid for one year from issuance. Thank you.

E Mail

Amity Township Contractor's License Application