BUCKINGHAM TOWNSHIP SUBDIVISION AND LAND DEVELOPMENT APPLICATION

BUCKINGHAM TOWNSHIP SUBDIVISION AND LAND DEVELOPMENT APPLICATION Pal t I (to be completed by Township) Date Application Received Received by (initials) Twp. Identification No., _ Application for: Type of Plan: Preliminary Plan Review Final Plan Review Minor Subdivision Major Subdivision Land Development Lot Line Change (I to lots) (3 or more lots) Fees Paid: See Current Township Fee Schedule (adopted annually) Submission $ Escrow $ - --- - Planning Modules Fees: 3-14 Lots $1,000 Escrow $,000 --- 15+ Lots $5,000 Escrow $15,000 _ Plan Tentatively Scheduled for Planning Commission on Pal t II (to be completed by Applicant) 1. Applicant: Name Telephone No. _ Address E-MaiIA~d~d~r-es-s----------------------------. Owner of Record (if corporation, list corporation's name and address, and names of two officers): Name Telephone No. Name Telephone No. ---------- Address. E-Mail Address 3. Agent or Attorney: Name Telephone No. _ Address,c-:-:- E-Mail Address _ 4. Engineer or Surveyor: Name Telephone No. Address,c-:-:- _ E-Mail Address 5. To whom should official notices/invoices for this submission be sent to? 6. If property was previously subdivided please provide the following information: Plan Title: Date of Plan _ Tax Parcel No. -,---:-:::---::-c:--- - - County Deed Book No. Page No. County Plan Book and Page No. (Note: A copy of the deed or agreement of sale shall be submitted with this app.) Applicafiol1jo/'l/1updafed 3/0/17

Page of 8 - Buckingham Township Subdivision and Land Development Application 7. Proposed Development Detail a. Zoning District Tax Parcel Number(s) b. Proposed Use (check applicable use/s): Single Family Residential _ Commercial Use Other: _ Multi-Family Residential _ Industrial Use c. If Residential: Number of Lots or Units - -- or If Non-Residential: Number of Lots Units or Leaseholds; Lots Units Leaseholds d. Proposed Use ofpropelty (Include brief description) e. Proposed New Building Area sq. ft. f. Proposed Density (units per acre) _ g. Total Area to be developed or subdivided (acres) _ 8. Water Supply (check one): Public - Identify System Individual On-Site (Refer to Well Ordinance #003-06 - Hydrogeologic Report or Well Testing will be Required) Community (Refer to Well Ordinance #003-06 - Hydrogeologic Report or Well Testing will be Required) 9. Sanitary Sewage Disposal (check one): 'Public - Identify System _ * 'Individual On-Site (Planning Modules Required) Community (Planning Modules Required) 'Planning Modules or "Exemption Request" (Attachment A - part A) must be submitted. " Plan ning Modules MUST be subm itted whether or not an "Exception Request" (Attachment A - palt B) is submitted. The undersigned represents that to the best of his or her knowledge, all of the above statements are true, correct and complete. I1We hereby authorize members of Township Boards, commissions and staff to enter the lands proposed for subdivision or land development for site inspections, if necessary. Further, I/we and my/our successor(s) in this application agree to reimburse the Township of Buckingham for such fees and expenses as said Township may incur for engineering, legal services and administrative fees in reviewing and advising the Board of Supervisors and Planning Commission with respect to this application. Further, I/we agree to provide all filing fees and escrow deposits as established by Resolution of the Board of Supervisors. Date Signature of Owner of Record/Applicant/Agent (Print Name and Sign)

Page 3 of 8 - Bucldngham Township Subdivision and Land Development Application Part III - Supplemental Information (to be supplied by applicant) I. Applicant shall submit with Application the items and number requested as listed below. Full and complete submissions will be stamped in by the Township and forwarded to proper agencies by either the Township or Applicant. The Application will not be accepted if any of the items required below are not provided. The Following Items are Required for ALL Applications Documents No, of Copies Reguit'ed Received by Twp, Application Form 1 (completed in full, proper fees submitted, app. signed) Deed (with deed restrictions/covenants, if any) Plans (Complete Sets) 6 Plan Sets must include Site Analysis ResoUl'ce Conservation Plan including Aerial Photograph of site (per Section 3.3. SD/LD Ord.) Noticc: No Application shall be accepted unless the plans have been prepared by a Registered Engineer or Surveyor. Stormwater Management / Erosion and Sediment Control Narrative (per Section 9.3 & Section 10 SD/LD Ord.) Act 537 Planning Module Reviews OR Completed 3 complete sets "Exemption and Exception Request" (Attachment A) including plans (per Section 3.I.E SD/LD Ord.) OR 1 Completed Attachment A Must be submitted with PRELIMINARY Application FEES: 3 to 14 lots - $1,000.00 / Escrow $,000.00 15+ lots - $5,000.00/ Escrow $15,000.00 Historic Resource Study (per Section 306 Zoning Ordinance) W-9 FOl'm - Request for Taxpayer Identification No, and Cel'tification 1 Major Subdivision 01' Land Development Application Additional Requirements (per Section 5. 1. SD/LD Ord.) Documents No, of Copies Reguit'ed Received by Twp, I) Information Packet w / llxl7 plan sheet ) All required docwnentation (plans, application, storm water reports, traffic studies, etc.) shall also be submitted in PDF Format on a CD

Page 4 of 8 - Buclungham Township Subdivision and Land Development Application The Following Items May be Required Depending Upon Specifics of the Application Documents # of Copies Required Received by Twp. Waiver Request Waivers which are requested from the requirements of the Subdivision/Land Development Ordinance must be listed in writing by letter or 011 the plan, with an explanation as to the reason for the request and the specific hardship associated with meeting the requirement. Transportation/T.-affic Impact Study (per Section 9.37. SO/LD Ord. and Section 305(A) Zoning Ord.) Required for major subdivisions and land developments that are: a. Residential 10 or more units, or that propose new roadways b. Non-Residential that provide 10 or more parking spaces c. As requested by the Board of Supervisors Environmental Impact Assessment Report a. Residential: 0 or more dwelling units b. Any application requesting establishment of a facility (per Appendix A) Zoning Ordinance per Section 305 (C) Zoning Ordinance Welll)ermit (as required by Ordinance 003-06) Water Resoul'ces Impact Study (pel' Well Ordinance 003-06, Table V-I & Section 305(B) Zoning Ord.) Required for subdivisions and land developments that are: a. Public Water Supply: Residential 4 or more units Private Water Supply: Required for ALL Submissions in accordance with requirements of Article 5 of the Twp. Well Ordinance (pel' Section 9.6. SD/LD Ord.) b. Land Development withdrawing in excess of 1,000 gpd Economic Impact Study Retail stores with proposed floor area of more than 7,500 sq.ft. (per Section 305(0) Zoning Ordinance) Hydrogeologic Study for Potential Public Water Systems (pel' SO/LO Ordinance I Section 9.5) Public Water shall be required for the following uses: I. Twenty five (5) or more single family homes. All multi-family developments 3. Manufactured home/mobile home developments 4. Life care facilities, hospitals, schools, nursing homes, gas stations, motor vehicle repair and any non-residential use that employs storage for dispensing of any substance that is a potential source of contamination (PSOC). Carbonate (Limestone) Geology Map If located within, or within 00 feet of, areas identified as having carbonate limestone geology (per Section 9.38. SD/LD Ord.)

Page 5 of 8 - Buckingham Township Subdivision and Land Development Application The Following Items May be Required Depending Upon Specifics of the Application (Cont'd.) Documents Wetlands Delineation Report Required for all properties where wetlands exist (per Section 9.4. SD/LD Ord.) Site Capacity Calculations Required for uses B I, B, B3, B4, B 13, and B 14 (per Section 3 1018 of Zoning Ord.) List of l)ermits Required from Other Governmental Agencies # of Copies Required Received by Twp.. Listed below are agencies othel' than the Township, which may requij'e materials 01' documents to be submitted directly by the applicant in connection with this application (list may not be all-inclusive, applicant is responsible for fulfilling requij'ements from various agencies): Bucks County Planning Conmlission Bucks County Conservation District Bucks County Health Department PA Dept. of Environmental Protection PA Department of Transportation U.S. Corps. of Army Engineers As required by BCPC As required by BCCD As required by BCHD As required by PADEP As required by PENN-DOT 3. At FINAL Submission - ALL OUTSTANDING FEES MUST BE PAID IN FULL

lpage 6 of 8 - Buckingham Township Subdivision and Land Development Applicationl BUCKINGHAM TOWNSHIP SUBDIVISION \ LAND DEVELOPMENT APPLICATION "ATTACHMENT A" EXEMPTION AND EXCEPTION REQUESTS WASTEWATER FACILITIES PLANNING This form is to be used for subdivisions and land developments requesting exemptions and exceptions from the requirements for wastewater facilities planning under the provisions of the Pennsylvania Code Title 5, Chapter 7\, Section 71.51 and Section 71.55. Development name Township SAl LD Number Applicant name Development proposed PART "A" EXEMPTION REQUEST (Planning modules not required) 1. PROPOSED USE OF ON-LOT W ASTEW ATER DISPOSAL SYSTEMS The official plan shows that the area Ves - - No - - Signature of Township manager or water and where the proposed development is located is to be served by onlot sewage disposal facilities using a soil absorption area or a spray field. sewer consultant required: The area proposed for the use of individual or community sewage Ves -- No - - systems is not underlain by carbonate geology nor is this area within 1/4 mile of water supplies documented to exceed 5 PPM nih'ate-nitrogen as confirmed by the Depal1ment fi'om a USGS geo logy map or sampling data. The area proposed for development is must be outside of high quality or exceptional value watersheds. Please include the new land development plotted on a USGS topographic quadrangle map. A USGS map is required with the development shown on it 011 it

ipage 7 of 8 - Buckingham Township Subdivision and Land Development Applicationi Are the subdivided lots and the Yes - - - No --- Signature of the Applicant required: remaining p0l1ion of the original tract after subdivision one acre or larger? Has complete soils testing and a site Yes - - - No --- Report from the Depaltment of health evaluation established that separate required sites are available for both a permittable primary soil absorption area or spray field and a replacement soil absorption area or spray field on each lot of the subdivision as confirmed by a signed report of the Department of Health?. PROPOSED CONNECTIONS TO PUBLIC SEWER Number of dwelling units: Estimated wastewater flow: Name of proposed collection system: Name of proposed conveyance system: Name of proposed treatment facility: I-las the Deparhnent of Yes --- No --- Signalllre of the Department of Environmental Protection Environmental Protection official or detennined that existing collection, attached letter: conveyance and treatment facilities are in compliance with The Clean Streams Law and the rules and regulations thereunder? Has the DEP determined that the Yes --- No --- Signature of the Department of permittees of the receiving sewerage Environmental Protection official or facilities have submitted information attached letter: under Chapter 94 (relating to municipal waste load management) which documents that the existing collection, conveyance and treatment system does not have an existing hydraulic or organic overload or 5-year projected overload?

IPage 8 of 8 - Buckingham Township Subdivision and Land Development Applicationl Written certification fi'om the Collection: Ves -- No -- Signature of the Depaltment of permittees oflhe couection, Environmental Protection official: conveyance and treatment facilities Conveyance: Ves -- No -- to the municipality in which the subdivision is located and the Treatment: Ves -- No -- Department that there is capacity to receive and treat the sewage flows fi'om the applicant's proposed new Signature of collection, conveyance and land development and that the h-eatment system owners or attached additional wasteload trom the letter(s): proposed new land development will not create a hydraulic or organic Collection: overload or 5-year projected (Signalure/Datc) overload. Conveyance: (SignalurelDatc) Treahnent: (SignaturelDate) PART "B" EXCEPTION REQUEST (Planning Modules Required) 1. PROPOSED USE OF ON-LOT WASTEWATER DISPOSAL SYSTEMS Does the subdivision involve 10 or Ves No - - - -- fewer single family lots? Are there any other existing (created Ves -- No --- after May 15, 197) or proposed lots associated with the subdivision? Has the Department ofheallh Ves - - No - -- A letter fi'om the Department of Health is approved the soil and site conditions required. as being generally suitable for onlot sewage disposal systems? P/mlllillg modules IllIll't slill be submitted fo/' all /'efjlle~'fs/01' exceptiolls. The modules fire required 10 be processed the same as ai/ otitel' modules except DEP lias on/jllllil'tv llfois to (let 011 {"em.

Form W-9 (Rev. December 014) Department of the Treasury Internal Revenue Service Name Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. N r.~8buw,"rnrue",~s~~~~~r.r,~mii~n"arrm",e'.~rrffi",","~nabove-------------------------------------------------------------------- '" ~e_------------------------------------------------------------------------_r---------------------- ~ 3 Check approprlate box for federal tax classlflcallon; check only one of the following seven boxes: ~~~~mtnt~~~~,(~~1~~d~~~~a?~i~~~ o 0 IndividuaVsole proprietor or 0 C Corporation 0 8 Corporation 0 Partnership 0 TrusVestale instructions on page 3): ~ single-member LLC.i' +I 0 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)'".,-,. Exempt payee code (if any) 5 Note. For a si ngle ~m ember LLC that Is disregarded, do not check LLC; check the appropriate box in the line above for Exemption from FATCA reporting c t) the tax classification of the single-member owner. code Of any) 0. 0 (AppUes 10 "ccounts ma/ntalned outside lhe u.s.).c.e~~~~;r-- ~~~~~ '" ' ~h.~~~~~~~----------------------------------~ (f) '" ~~~~~----------~~---------- Enter your TIN in the appropriate box. The TIN provided must match name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other entities, it Is your employer identification number (EIN), If you do not have a number, see How to get a TIN on page 3. Note. If the account is In more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter, Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer Identification number (or I am waiting for a number to be issued to me); and, I am not subject to backup withholding because: (a) I am exempt from backup withholding. or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on page 3. Sign Signature of Here u.s. person ti>- Date'" General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) Is at www.irs.govlfw9. Purpose of Form An individual or entity (Form W-9 requester) who Is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your social security number (SSN), Individual taxpayer Identification number (ITIN). adoption taxpayer Identification number (ATIN), or employer Identification number (EIN), to report on an lnformallon return the amount paid to you, or other amount reportable on an Informallon return. Examples of Information returns include, but are not limited to, the following: Form 1099-INT ~nterest earned or paid) Form 1 099-0 1V (dividends, including those from stocks or mutual funds) Form 1 09S-MISC (various types of Income, prizes, awards, or gross proceeds) Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) Form 1099-8 (proceeds from real estate transactions) Form 1 099-K (merchant card and third party network transactions) Form 1098 (home mortgage interest), 1098-E (student loan Interest), 1098-T (tuluon) Form 1099-C (canceled debt) Form 1099 ~A (acquisition or abandonment of secured property) Use Form W-9 only if.you are a U.S. person ~ncluding a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. Sea WlJat Is backup wilhholding? on page. By Signing the filled-out form, you: 1. Certify that the TIN you are giving Is correct (or you are waiting for a number to be Issued),. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding If you are a U,S. exempt payee. If appllcable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business Is not subject to the withholding tax on foreign partners' share of effectively connected income. and 4. Certify that FATCA code(s) entered on this form Of any) Indicating that you are exempt from the FATCA reporting, is correct. See What Is FATCA reporting? on page for further Information. Cat. No. 1031X Form W-9 (Rev. 1-01 4)