Fillable Application for Six Month Extension on Installation Permit (Arizona)

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Application for Six Month Extension on Installation Permit (Arizona)

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The Application for Six Month Extension on Installation Permit (Arizona) form is 2 pages long and contains:

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  • 18 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

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1110 WEST WASHINGTON, SUITE 280
PHOENIX, ARIZONA 85007
PHONE: 602-771-1000 | FAX: 602-771-1002
WWW.AZHOUSING.GOV
Application for Six Month Extension on Installation Permit
Today’s Date: ______________________________________
Applicant Name: __________________________________________________________________________
Email Address: ___________________________________________________________________________
Permit Number: ____________________________________ (Only one permit per request)
Date Permit Issued: _________________________________
Every permit except for a special use permit expires 6 months from the date the permit is issued.
Extension request must be received by the Department prior to the expiration date; the Director may grant a one-
time extension for a period not to exceed 180 days if justifiable cause is demonstrated.
Detailed explanation for requesting extension:
ATTACH ADDITIONAL SHEET(S) IF NECESSARY
CONTINUED ON NEXT PAGE
Application for Six Month Extension on Installation Permit
Have any changes been made to the original Installer, Contractor and/or Subcontractor noted on permit?
NO YES If yes, please provide current Installer, Contractor, and/or Subcontractor information.
Company Name __________________________________________________________________________________
License Number ___________________ License Classification ____________ Phone Number ________________
Email Address ____________________________________________________________________________________
Check work being performed ELECTRIC PLUMBING GAS MECHANICAL
ACCESSORY STRUCTURE _____________________________________________________________________
OTHER _______________________________________________________________________________________
Company Name ___________________________________________________________________________________
License Number ___________________ License Classification ____________ Phone Number ________________
Email Address ____________________________________________________________________________________
Check work being performed ELECTRIC PLUMBING GAS MECHANICAL
ACCESSORY STRUCTURE _____________________________________________________________________
OTHER _______________________________________________________________________________________
Company Name ___________________________________________________________________________________
License Number ___________________ License Classification ____________ Phone Number ________________
Email Address ____________________________________________________________________________________
Check work being performed ELECTRIC PLUMBING GAS MECHANICAL
ACCESSORY STRUCTURE _____________________________________________________________________
OTHER _______________________________________________________________________________________
ATTACH ADDITIONAL SHEET(S) IF NECESSARY
THIS SECTION IS FOR OFFICE USE ONLY
Approved ____________________
NEW EXPIRATION DATE
Denied
Processed By:
Date Processed:
Fee Received:
Check #:
Receipt # :
COMMENTS:
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Application for Six Month Extension on Installation Permit (Arizona)

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Completed 12 August 2020

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