Fillable Change Certificate Application (Maricopa County Telecommunications)

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Change Certificate Application (Maricopa County Telecommunications)

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The Change Certificate Application (Maricopa County Telecommunications) form is 2 pages long and contains:

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  • 2 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

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Revised October 2018 - Fillable
Maricopa County
Environmental Services
Maricopa County Environmental Services Department
Subdivision, Infrastructure and Planning Program
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Change Certificate Application
(PLEASE TYPE OR PRINT CLEARLY)
Contact Person:
Title
E-mail address of contact person
Company Name:
Phone number:
Ext:
Fax Number:
Address:
City:
State:
Zip Code:
Please Mark the Appropriate Box Below
Change Project Name
Owner Name
Fee
-
$200.00 per certificate
T
his form to be used when changing either the Project Name or Owner Name on a previously approved
subdivision. (May also be used for other projects only if deemed by the SIPP Staff.)
Provide supporting documentation verifying/confirming the change: Amended Plat, correspondence, etc.
Provide the OLD/current information including issued MCESD number and NEW/requested information in the
spaces provided. MCESD will then provide new numbers.
Project Owner / Responsible Party must sign the application. This person must be a person with fiduciary
responsibilities associated with the Project or Company.
Provide a copy of previously issued certificate with corrections indicated also.
The fee is $200 Per Certificate. If a project has both Project Name Change AND Owner Change, the fee is
$200 if submitted at same time
.
Any questions contact Cindy Furze at 602-506-1058 or CFurze@Maricopa.gov ***
The Department reserves the right to request any other information ***
Page 1 of 2 Visit our web page at www.maricopa.gov/EnvSvc/WaterWaste/Subdivisions/Subdivisions.aspx
Revised October 2018 - Fillable
Maricopa County
Environmental Services
Maricopa County Environmental Services Department
Subdivision, Infrastructure and Planning Program
501 N. 44
th
., Suite 200
Phoenix, AZ 85008
Change Certificate Application
Change Project Name
OLD Project Name:
MCESD #
MCESD #
MCESD #
NEW Project Name:
MCESD #
MCESD #
MCESD #
Change Project Owner
OLD Project Owner:
Job Title
MCESD #
MCESD #
MCESD #
NEW Project Owner:
Job Title
MCESD #
MCESD #
MCESD #
(Please type or print legibly) (The information will be used on the Certificate)
(Owner must be a PERSON with fiduciary responsibilities associated with the Company)
Project Owner Name
Project Company Name
Project Company Mailing Address
City
State
Zip Code
Phone Number
Ext
Fax Number
Email address
Authorization
The Project Owner hereby authorizes the review of project plans as described for approval to construct and/or provisional verification of
conformance under General Aquifer Protection Permit 4.01.
_______________________\____________________ ______________________________
Signature of Project Owner \ Please print name Date
Department Use Only
Check number (s)
Amount Paid
Page 2 of 2
Any questions contact Cindy Furze at 602-506-1058 or CFurze@
M
aricopa.gov
*** The Department reserves the right to request any other information ***
Visit our web page at www.maricopa.gov/EnvSvc/WaterWaste/Subdivisions/Subdivision.aspx
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Change Certificate Application (Maricopa County Telecommunications)

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Completed 6 August 2020

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