CITY
OF LOCK HAVEN
DEPARTMENT
OF CODE ENFORCEMENT
LOCK
HAVEN, PENNSYLVANIA
Date
Received ______________________________
**THE WORKERS COMPENSATION REFORM ACT
"ACT 44" REQUIRES THAT ALL CONTRACTORS PROVIDE PROOF OF WORKERS
COMPENSATION INSURANCE BEFORE A PERMIT WILL BE ISSUED OR A
NOTARIZED AFFIDAVIT THAT INSURANCE IS NOT REQUIRED UNDER ACT 44.
**CITY RESOLUTION #848 REQUIRES THAT ALL
CONTRACTORS PROVIDE PROOF OF LIABILITY INSURANCE BEFORE A PERMIT
WILL BE ISSUED.
1. Applicant: Name_________________________________________________________________
Address_______________________________________________________________
Phone
Number__________________________________________________________
2. Firm Erecting Sign: Name_________________________________________________________________
Address_______________________________________________________________
Phone
Number__________________________________________________________
3. Owner of Business: Name_________________________________________________________________
(Signature of Business Owner)
Address_______________________________________________________________
Phone
Number__________________________________________________________
4. Owner of Structure: Name_________________________________________________________________
Signature
______________________________________________________________
5. Location of Sign: Street No. and Name______________________________________________________
6.
Type of Sign Shape Size Height
Above Ground
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D |
O |
ƒ |
□ |
Square Feet |
Horiz. Dimension |
Vert. Dimension |
Top |
Bottom |
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*Whether: Projecting, Wall-Mounted, Ground-Pole, Directional, Off
Premise or Real Estate type sign, or Window (Hanging or Painted). Indicate whether
sign is permanent or temporary by putting the symbol "P" or
"T" after each.
7. Number of signs on premises at present
time___________________
Permanent: Projecting
( ); Wall-Mounted ( ); Directional ( ); Off-Premises ( ); Real Estate ( ); Free
Standing ( ); Hanging Window ( ); Painted Window ( ).
Temporary: Projecting
( ); Wall-Mounted ( ); Directional ( ); Off-Premises ( ); Real Estate ( ); Free
Standing ( ); Hanging Window ( ); Painted Window ( ).
Plans of proposed sign must be attached to
this application.
8. Action by Sign Inspector: Approved ( ); Disapproved ( ).
Date_______________________________
By________________________________
Permit
No.__________________________
Remarks by Sign Inspector:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Fee
$_______________________________
Show below location of building, structure or
lot which sign is to be attached or erected, size of sign, relation to buildings, etc.
ALL EXISTING SIGNS
MUST BE SHOWN.
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