P_038_F (Rev 12.2023) Page 1 of 1
Project Owner or Owner Representative Name: _______________________________________________________________________________________
Signature: _ Date: / /
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Acknowledgment of Receipt
of Construction or Demolition Project Information
Required Project Details
The Contractor is the contractor
identified on the applicable permit
application as responsible for the
construction authorized by the
permit, in accordance with Section 9-
1004 of the Philadelphia Code.
A new building or addition extending
above an existing chimney or vent
on an adjacent roof may require the
extension of chimney / vent. Refer to
the Chimney / Vent Clearance
Requirements Information Sheet for
more information.
B
The following information must be provided to the property owner registered with the Office of Property
Assessment:
Project Information (Mandatory)
• A description of the nature of work
• An estimated schedule and duration
• A pre-construction survey and plans or details depicting
work that may affect the adjoining / adjacent property
• Details of monitoring to be performed
on t
he adjacent property
• Protection proposed to be installe
d on
t
he adjoining property
Is Chimney / Vent Extension Required: ☐ No ☐ Yes
• If ‘Yes’, a Notice of Required Chimney / Vent Modification must be provided.
Contractor Information
• The Contractor’s contact information for the project
• A copy of the Contractor’s Certificate of Insurance for general liability
OR
☐ Check this box if a contractor has not yet been selected. The contractor’s contact information
and
insurance shall be provided with the final notice at least 10 days prior to the start of work.
Project Information
A
In accordance with Section 4-B-3307.11.1 of the Philadelphia Code, the owner or their representative causing construction or demolition is required to provide
an adjacent owner, as registered with the Office of Property Assessment, with pertinent project information where work may impact the adjacent property.
The affected adjacent owner or their representative must sign Section C of this form to acknowledge receipt of project information and the form(s) must be
submitted with the permit application. If a reasonable attempt has been made to provide required information but a signature could not be secured, no permit
shall be issued in less than 60 calendar days of submission.
Project Address: ________________________________________________________________
Type of Work: ☐ New Construction ☐ Demolition ☐ Addition/ Alteration
Adjacent Property Owner
Acknowledgement
An affected property is one which:
1. is within 10 ft of an excavatio
n
m
ore than 5 ft below adjacent
grade
2. share a party wall
3. are on the Philadelphia Historic
Registry with buildings located
within 90 ft.
4. share a common structural, roof, or
wall element that is being severed.
If more than one property is
affected, a separate form shall be
submitted for each property.
Affected Property Address: _________________________________________________________________
B
y signing below, I acknowledge that I was provided with the information listed in Section B. This serves only to
acknowledge receipt and does not constitute an agreement to enter property, perform work on property, or
otherwise waive any legal rights of the property owner.
N
ame of Owner or Representative*: __________________________________________________________
Signature: __________________________________________________ Date: _____________________
*
If adjacent property is a condominium or planned unit development, the signature of an authorized association
representative shall suffice.
C
Notice of Failed Attempt
Complete this section only if unable
to secure signature of affected
adjacent owner or representative.
Proof of delivery (i.e., include certified
mail receipt) must be submitted with
the permit application.
D
☐
A reasonable attempt has been made to secure the adjacent owner’s signature confirming receipt, however,
I am unable to obtain the signature of owner of the adjacent property or properties confirming delivery. I
understand that my permit shall not be issued less than 60 days from the application date.
A
ffected Property Address: _________________________________________________________________
