Mailing Address:
P.O. Box 4008, MS 401
Chandler, Arizona 85244-4008
Development Services Department
Building Safety Division
215 E. Buffalo St., Chandler Arizona 85225
Telephone: (480) 782-3000
Form No. UDM-062/Building
Rev: 12-30-19
Facility Name:________________________________ Square footage (
campus total
Facility Address:___________________________________________________________________
Additional building addresses (
must be on same campus
): _____________________________________
Facility Agent (
Arizona Registrant or other as approved by the Building Official
) Registrant? ___Y ___N
Name:__________________________________ Phone:_____________ Certificate # ___________
Email Address:____________________________________________________________________
Mailing Address:___________________________________________________________________
By submitting this application you are certifying that the facility owner’s agent currently resides in the state of
Arizona. If the representative moves out of state, or is otherwise replaced, then a new application must be
Other facility contact: Name __________________________________Title: __________________
Email Address: ____________________________________________ Phone: _________________
Trust account contact (
if different
) Name:_________________________________________________
Email _______________________________________ Phone ______________________________
For City Use:
Application Fee ________ Trust account _______________ Approved date: _________________
Approved by: Expiration date:
Permit or log #
Registration Application
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