Development Name ______________________________________________________

Site Location ____________________________________________________________

Legal Property Owner *: Name:______________________________________________

Address: _______________________________________________________________

Phone: _____________________Fax _____________________

Contact Person**

Name: _________________________________________________________________

Address: _______________________________________________________________

Phone: ____________________Fax_____________________

**The contact person is the one to whom all correspondence will be sent.

Interest of applicant is: ( ) Owner ( ) Equitable Owner ( ) Other – explain _________________

________________________________________________________________________

Zoning Information:

District ______________

Statement of Intent:________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Please complete the following items which are applicable to your project.

Attorney’s Name _______________________________________________

Address _______________________________________________

Phone # ___________________________Fax #________________

Engineer’s Name _______________________________________________

Address _______________________________________________

Phone # _________________________ Fax # _________________

I certify that the plans submitted comply with the requirements of Article V of the Upper Providence Township Subdivision and Land Development Ordinance except as noted below (also state the reason why the subdivision does not comply with the noted exception):

Plan submitted by ___________________________________________(please print)

Applicant’s Signature ________________________________________

Application Fee: $__________________ Escrow Amount: $________________

___ Attached ___Attached

___ Under Separate Cover ___Under Separate Cover

-------------------------------------------------------FOR OFFICE USE ONLY -------------------------------------------------------

Date Received __________________ Date Received_________________

Check # _______________________ Check # _____________________

Plans accepted by _______________

Date plans accepted ______________