Fillable Application Submittal (Maricopa County Telecommunications)

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Application Submittal (Maricopa County Telecommunications)

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Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
DUST CONTROL PERMIT APPLICATION - SECTION 1, APPLICATION
Revised 12 June 2020
For Office Use Only
Permit Number: Date Issued:
Application Submittal
Applications and payment may be submitted in person or mailed to either of the following locations:
1. Maricopa County Air Quality Department, 3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
2. One Stop Shop, 501 N. 44th St., Suite 200, Phoenix, AZ 85008
For a completed application, a Dust Control Permit Application (section 1) and a Dust Control Plan (section 2) will need to
be submitted. Rule 310, Section 402 (dust control plan requirements) requires the submission of a dust control plan with your
application. The Dust Control Plan is located at Maricopa.gov/1818.
No-Permit Violations: Did you receive a no-permit violation?
If so, provide the permit number given to you by the inspector
NoYes
Permit Number:
Is this a re-application? If "Yes", provide previous permit number
A permit is valid for one year after the date of approval. You must re-apply for a permit more than 14 calendar days before the original permit expires. The re-
application process may take up to 14 calendar days for review and processing (not including time for postal delivery) and must be approved prior to the
expiration of the old permit.
NoYes
Permit Number:
Provide and e-mail address where we can send the permit:
Applicant Information
For all applicants, appropriate registration in the State of Arizona will be verified with the Arizona Corporation Commission or other applicable
resources before a permit will be issued.
1. Applicant
Relationship to property (Check all that apply):
Property Owner
General/Prime Contractor Developer Lessee
Type of Entity:
Corporation
Limited Liability Company or Partnership Sole Proprietor Individual Government
Name:
Address:
City:
State:
Zip:
E-Mail Address:
Phone:
2. Is applicant a wholly owned subsidiary of another company?
If "Yes", please provide all requested information below. If "No", please proceed to question 3.
Type of Entity:
Parent Company (if applicant is wholly owned subsidiary)
Yes
No
Corporation
Limited Liability Company or Partnership Sole Proprietor Individual Government
Address:
State of Incorporation or Registration:
Contact Name:
City:
State: Zip:
Phone:
E-Mail Address:
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
DUST CONTROL PERMIT APPLICATION - SECTION 1, APPLICATION
Revised 12 June 2020
Address:
City: State: Zip:
Phone: E-Mail Address:
Name:
3. Applicant President/Owner
4. Property Owner/Developer (if not applicant)
Address:
Company Name:
City: State: Zip:
Contact Name:
Type of Entity:
Corporation
Limited Liability Company or Partnership Sole Proprietor Individual Government
E-Mail Address:
Phone:
Name:
Company Name: Title:
On-Site Phone: Mobile:
5. Dust Control Coordinator
All sites with five or more acres of disturbed surface area that are subject to rule 310 must have a dust control coordinator on site at all times
during dust-generating operations. The dust control coordinator(s) must complete 310 comprehensive training. List any additional dust control
coordinators on a separate sheet of paper and attach to this application if necessary.
E-Mail Address:
6. Primary Project Contact
Provide a primary project contact/authorized on-site representative for this site. State if the primary project contact is already referenced in
section 5 above or provide all of the following information.
Name:
Company Name: Title:
On-Site Phone: Mobile:
E-Mail Address:
Project Information
7. Name of Project:
8. Project Location
Address:
City: Zip:
Nearest Major Cross Street North/South:
Nearest Major Cross Street East/West:
County Assessor’s Parcel Number(s) (required):
Master Plan Community Number(s) (if applicable):
Geographic Coordinates (lat./long. coordinates of site entrance):
State: AZ
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
DUST CONTROL PERMIT APPLICATION - SECTION 1, APPLICATION
Revised 12 June 2020
9. Project Location by Township (N or S), Range (E or W), Section (1-36)
Range:Township: Section:
10. Brief Project Description:
11. Size of Project
Total cubic yards of bulk material to be imported/exported:
Total acres that will be disturbed throughout the duration of this permit including; staging
areas, stockpiles, access and haul roads, parking, driveways, and temporary storage yards:
12. Project Site Drawing: A dust control permit will not be issued unless a project site drawing is submitted.
Attach a separate document with a drawing showing all of the following elements:
• Entire project site boundaries and disturbed surface area boundaries
• Area to be disturbed with linear dimensions or certification of square footage (including staging areas, stockpiles, access and haul
roads, parking, driveways, and storage)
• Nearest main crossroads
• North arrow
• Access point(s) - planned exit locations onto areas accessible to the public
• Unpaved parking lot(s)
Example (simplified, not to scale):
13. Estimated Project Start Date (month/day/year). If this is a re-application, list the original project start date:
14. Estimated Project Completion Date (month/day/year). This date may be beyond the one year duration
of the permit:
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
DUST CONTROL PERMIT APPLICATION - SECTION 1, APPLICATION
Revised 12 June 2020
The Maricopa County Air Quality Department regulates all asbestos renovation and demolition within Maricopa County. An
overview of Asbestos National Emission Standards for Hazardous Air Pollutants (NESHAP) requirements are available in the
Asbestos NESHAP brochure at Maricopa.gov/DocumentCenter/View/5064.
15. Asbestos NESHAP Notification Requirements
Demolition: The wrecking or taking out of any load-supporting structural member of a facility together with any related handling
operations or the intentional burning of a facility.
Renovation: Altering a facility or one or more facility components in any way, including the stripping or removal of regulated asbestos
containing material (RACM) from a facility component.
Yes No
15a. Does the project include demolition or renovation?
If "Yes", provide all requested information below. If "No", proceed to section 16.
15b. Description of demolition/renovation activities:
Yes No
15c. Has the property ever been used as a ranch, farm, business or any other
commercial or industrial purpose?
Yes No
15d. Is there a guesthouse, more than one livable structure on the property,
or is work being done in conjunction with another property in the area?
Yes No
If you answered "No" to both questions 15c and 15d, skip to section 16.
If you answered "Yes" to either question 15c or 15d, proceed below.
15e. Has an asbestos inspection been conducted by an AHERA certified
building inspector within 12 months before any demolition/renovation
activities?
Yes No
15f. Has a 10-Day NESHAP notification form been submitted?
If "No", you may need to file a 10-day NESHAP notification form at Maricopa.gov/1701.
For more information, contact the department at 602-506-6010.
15g. 10-Day NESHAP notification number:
Demolition notification number on file:
For Office Use Only
Approved by:
Renovation notification number on file: Date approved:
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
AQPermits@maricopa.gov
DUST CONTROL PERMIT APPLICATION - SECTION 1, APPLICATION
Revised 12 June 2020
Signature(s)
16. Certification by a Responsible Official of the Applicant
A Responsible Official of the Applicant is the person who will be contacted or named in any enforcement action initiated by the
Maricopa County Air Quality Department or the Maricopa County Attorney's Office. Pursuant to Rule 310, Section 401.3, the signature
on the Dust Control Permit Application shall constitute agreement to accept responsibility for meeting the conditions of the Dust
Control Permit and for ensuring that control measures are implemented throughout the project site and during the duration of the
project.
Arizona Revised Statute § 13-2704 makes it a criminal offense to knowingly make a false material statement to a public servant in
connection with an application for any benefit, privilege, or license.
I hereby certify that, based on information and belief formed after reasonable inquiry, the statements and information in the Dust
Control Permit Application, including Applicant Information, Project Information, and the Dust Control Plan, are true, accurate, and
complete.
Notice of Regulatory Reform in accordance with A.R.S. §11-1604
A. A county shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by
statute, rule, ordinance or delegation agreement. A general grant of authority does not constitute a basis for imposing a licensing
requirement or condition unless the authority specifically authorizes the requirement or condition.
B. Unless specifically authorized, a county shall avoid duplication of other laws that do not enhance regulatory clarity and shall avoid dual
permitting to the maximum extent practicable.
C. This section does not prohibit county flexibility to issue licenses or adopt ordinances or codes.
D. A county shall not request or initiate discussions with a person about waiving that person's rights.
E. This section may be enforced in a private civil action and relief may be awarded against a county. The court may award reasonable attorney
fees, damages and all fees associated with the license application to a party that prevails in an action against a county for a violation of this
section.
F. A county employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or
dismissal pursuant to the county's adopted personnel policy.
G. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
*(note: a signature is not required if this form is submitted online)
Date:
Printed Name:
Title:
17. Application Completed By (if other than signatory)
Signature:
Date:
Printed Name:
Title:
E-Mail Address:Phone:
*Signature:
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Application Submittal (Maricopa County Telecommunications)

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Completed 6 August 2020

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