PLEASE COMPLETE PARTS A-F BELOW
PART A: DESCRIPTION OF PROPERTY Tax Parcel # __________________________________________
Site Location/Address: ______________________________________ City/State/Zip: _____________________________
Property Owner/Applicant name: _____________________________
Mailing Address: ___________________________________________ City/State/Zip: _____________________________
Phone Number: _________________________ Email: ______________________________________________________
PART B: PROPOSED PROJECT: ________________________________________________________________________
Square feet: __________ Height: __________ Estimated Value of Proposed project: $_____________
PART C: HEALTH SERVICES SECTION Sewer □ Septic System: □ IF SEPTIC SYSTEM: New □ Existing: □
PART D: OWNER/BUILDER INFORMATION – In Accordance with A.R.S. Title 32
□ I am currently a licensed contractor: Name: __________________________ Doing Business As: _________________
ROC License #: ______________________ Classification of ROC License: ______________________
□ I AM Owner/Builder: Name: _____________________________ Address: __________________________________
EXEMPTION FROM LICENSING
□ I am exempt from Arizona Contractors’ license laws on the basis of the licensing exemptions contained in A.R.S. 32-1121A.
□ I am the Owner/Builder of the property. I will follow in strict compliance with 32-1121A.5. The property is intended for
the sole occupancy by the owner, not intended for occupancy by members of the public: owner’s employees, or business
visitors. The structures are NOT INTENDED FOR SALE OR RENT WITHIN 1 YEAR AFTER COMPLETION.
PART F: CERTIFICATION SIGNATURE
I hereby certify that I am the owner or duly authorized owner’s agent and that all information on this application and the
attached site plan is accurate. I understand that if any of this information is false, it may be grounds for revocation of this
permit. I further certify that I will comply with all County, City and State and Federal regulations applicable to said property,
and acknowledge that I am not authorized to begin work until I have received a numbered permit. I FURTHER AUTHORIZE
COUNTY EMPLOYEES AND APPROPRIATE REGULATORY AGENCIES TO ENTER ONTO SAID PROPERTY TO MAKE REASONABLE
INSPECTIONS FOR COMPLIANCE.
Signature: ___________________________________________________ Date: __________________________________
County Assigned Address: ______________________________________________________________________________
Construction Plans: Yes □ No □ Flood Zone __________ Flood Panel __________ Flood Date: _____________
Total $___________
Permit Tech Approved: _______________________
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