Certification

I,

Hereby attest the attached information is true and accurate for the property located at

Signature of Applicant (required)

Name and Title (required)

Email Address (required)

SWORN AND SUBSCRIBED before me

Date (required)

Notary Public (required)

My Commission Expires (required)

I hereby authorize the Municipality of Penn Hills Appeals Board and the municipality Officials to view and to inspect the property which is the subject of this application at any time during the pendency of said Application and the construction related thereto.

Signature of Applicant (required)

Signature of Property Owner (required)