CITY OF EL MIRAGE
Building, Engineering,
Fire, Planning & Zoning
10000 N. El Mirage Road
El Mirage, AZ 85335
Phone (623) 251-3503
Fax (623) 876-4605
OFFICIAL USE ONLY
Permit No.:
Plan Review Fee/Deposit: (if applicable)
Total Permit Fees: (Balance due)
PROJECT ADDRESS: Submittal Date:
PROJECT NAME: Lot or Suite:
Subdivision Name: APN# Valuation:
Description of Work:
TYPE OF PERMIT:
_____ COMMERCIAL BLDG _____ RESIDENTIAL _____ ENGINEERING _____ FIRE ALARM/SPRINKLER
_____ TENANT IMPROVEMENT _____ ADDITION/PATIO _____ SIGN _____ OTHER:______________________
APPLICANT/CONTACT:
Phone:
Address: e-mail:
City: State: Zip code:
OWNER:
Phone:
Mailing Address: e-mail:
City: State: Zip Code:
CONTRACTOR:
Phone:
Address: e-mail:
City: State: Zip Code:
El Mirage Business License # ROC #
The undersigned, under penalty of perjury, does hereby certify that all improvements made to the above project, at
the address as stated above, by means of the building or improvement of structures or appurtenances of such property will be
performed by a duly licensed contractor unless the entire structure is intended for the undersigned’s sole occupancy.
I understand owners who sell or rent property with improvements not completed by a licensed general contractor,
may be subject to a Class 1 Misdemeanor under Arizona Revised Statutes §32-1151 and §32-1154. A Class 1Mis-
demeanor is punishable by a fine not to exceed $2,500 and /or one year in the County Jail. I understand and acknowledge
the above certification.
Owner/Applicant_________________________________________________________Date______________________
“quality community development through quality customer service”
