(Revision 03-2019)
Supervisor Dist.:
Reviewed By:
MCDOT TC NO.: Submitted By: Issue Date:
Expiration Date:
The undersigned herewith makes application for a permit to enter upon and use a portion of the right-of-way of the Public
Project Title:
Major Crossroads / Address:
in the , Of Section , Township , Range
for the purpose of:
Applicant Name (PRINT):
Address:
Contractor:
Contact Person:
Contact Email:
Owner:
Unit Cost
Unit Quant.
Amount
WATER -->
SEWER -->
PVMT -->
MISC. -->
OTHER -->
Professional Registrant Seal for Cost Estimate (if applicable)
SUBTOTAL PERMIT ITEMS (above)
PLAN REVIEW FEE @ $100/sht
PROCESSING FEE
PERMIT FEE (3% of Permit Items)
TOTAL FEE (Permit Fee + Review + Processing)
INSURANCE (Expiration Date):
BOND REQUIRED, Y N
*For questions regarding this permit application contact a MCD
OT right-of-way permit coordinator at (602) 506-7848, (602) 506-8791 or (602) 506-6216.
MARICOPA COUNTY DEPARTMENT OF TRANSPORTATION PERMIT
APPLICATION FOR CONSTRUCTION IN COUNTY RIGHT-OF-WAY
Applicant Signature:
Phone:
City, State, Zip Code:
Phone:
Fax:
Please answer the following related to this project:
ENTER PERMIT ITEMS:
[ ] Is this a MCDOT project? If so, please
provide name and/or number.
____________________________________
____________________________________
Is there an IGA for this project? If so, please
provide a copy.
If applicable, please provide the utility
company job number:
____________________________________
[ ] Is this a cell or wireless pro
ject?
[ ] Is this project subject to a license or
franchise agreement?
[ ] Is this related to a subdivision? If so,
please provide subdivision name:
____________________________________
____________________________________
Comments:
*Attach additional sheet if neces
sary for more permit items.
-------------- Below section for use by MCDOT permitting staff only -------------
Enter Total Sheets for Review by MCDOT:
click to sign
signature
click to edit
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