Commercial Temporary CO Form Rev: 11/02/12
LAKE HAVASU CITY
Community Services Department ♦ 2330 McCulloch Blvd. North ♦ Lake Havasu City, AZ 86403 ♦ 928-453-4148
REQUEST FOR TEMPORARY CERTIFICATE OF OCCUPANCY
FOR COMMERCIAL OR MULTI-FAMILY PROJECT
Project Name: _______________________________________________________________________
Project Address: _____________________________________________________________________
Tract: ______________ Block: ________________ Lot(s): ________________
I ___________________________________________________ am requesting a ______________________ day
(Property owner or business owner’s name) (Maximum 30 days)
Temporary Certificate of Occupancy pursuant to the requirements of Section 110.3 of the 2006 International
Building Code. I would like to occupy the building for the following reason(s):
[ ] Training [ ] Stocking [ ] Other (explain): _________________________________
___________________________________________________
Before the Certificate of Occupancy will be issued, I agree to complete the item(s) listed below: ______________
___________________________________________________________________________________________
___________________________________________________________________________________________
If the items above have not been inspected and approved by the appropriate departments by
______________________________, I understand my Temporary Certificate of Occupancy will be revoked and,
(expiration date)
without further notice, the City will automatically issue a citation(s), and/or revoke the bond and/or instruct the
utility company that electrical power must be disconnected.
_________________________________________________ ______________________________
Property Owner or Business Owner’s Signature Date
NOTARY ACKNOWLEDGMENT:
State of Arizona )
)
County of ___________________________ )
On this ___________ day of _____________________________, 20__________ before me personally appeared
__________________________________, whose identity was proved to me on the basis of satisfactory evidence to be the
person whose name is subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Seal:
____________________________________ _____________________
Notary Public My Commission Expires
FOR OFFICIAL USE / ACTION ONLY Submittal Date
[ ] Approved [ ] Denied
Building Official’s Signature
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