Fillable Project Address ARCHITECT OWNER Project Name Estimated Project (Lake Havasu City)

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Project Address ARCHITECT OWNER Project Name Estimated Project (Lake Havasu City)

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BROWSE LAKE HAVASU CITY (AZ) FORMS

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Rev. January 2018
INTERNAL USE:
Water
Development Engineering
Fire
#
Tract
Building Permit Driveway Permit: Primary Secondary
CONTRACTOR
OWNER
PLEASE CHECK PERSON RESPONSIBLE FOR WATER SERVICE BILLING. The undersigned applies for water service subject to all rules and regulations of the City.
•
•
•
•
•
Bond Exemption Cert.
Health Dept. Approval
Licensing Certification
Sprinkler
Prior Grade:
Max Grade:
Min. Grade:
Land Use:
Comments:
Building Fee: $
Retainer Fee: $ Permit Fee: $ PE:
0.00
Plan Check Fee:
$
Total Valuation: $
0.00
0.00
Authorized Use
:
sq. ft. @
=
sq. ft. @
=
Dwelling Units
:
0.00
No. Stories
:
sq. ft. @
=
0.00
sq. ft. @
=
Type of Const.
:
0.00
Census Class
:
sq. ft. @
=
0.00
sq. ft. @
=
Occupancy
:
FOR OFFICIAL USE ONLY
Zoning
VALUATIONS
All information must be filled in completely and must be legible or this application will not be accepted.
Changes may result in additional plan review fees.
PERMIT
EXPIRES 180 days from issuance (with no required inspections) or 180 days from last required inspection. Plans in re view status may be destroyed if not resubmitted or issued within 180 days.
No refund of plan check fees will be granted if plans have been reviewed by Plans Examiner. Permit fees may be refunded at 80% within 180 days of permit issuance if no work has commenced.
Consult with Mohave County Health Department concerning septic tank installation and percolation tests: kgmpermitstaff@mohavecounty.us .
Signature
Date
OWNER/BUILDER. I am exclusively contracting licensed contractors to construct the project or I or my employees will do the work. I understand that I must own the home for a period of
one (1) year following completion prior to renting, selling, or leasing the residence. Occupancy or use of any structure is not allowed until a Certificate of Occupancy is issued. Failure to
comply with this requirement may result in a civil infraction being filed.
I am authorized to file this application and the information is accurate and true to the best of my knowledge.
OWNER/APPLICANT FOR DRIVEWAY OR BACKFLOW PERMIT. I acknowledge and understand installation must be performed by a licensed contractor and that proof of contract may
be required at the time of inspection.
CONTRACTOR/AUTHORIZED AGENT. I accept responsibility that work to be conducted under an issued permit conforms to plans submitted in conjunction with this application and in
accordance with Lake Havasu City codes. Occupancy or use of any structure is not allowed until a Certificate of Occupancy is issued. Failure to comply with this requirement may result in a
civil infraction being filed. This permit application is filed on behalf of the property owner and the application and all accompanying plans and documents may be revoked or
transferred at any time by the property owner.
Size
___ Add to Existing
Water Meter Ir
rigation Meter Hot Tap Sewer Tap __Primary __Secondary
Backflow (Attach 2 site plans)
Fire Line
FIRE LINE
FIRE ALARM
FIRE SPRINKLER
DRIVEWAY
GRADING
POOL/SPA
PLUMBING
ELECTRICAL
GENERAL
MECHANICAL
Name
Mailing Address
Phone
State Lic # / Class
Bus. Lic. #
Name
Phone
Lot(s)
ARCHITECT
OWNER
LAKE HAVASU CITY ♦ COMMUNITY INVESTMENT DEPARTMENT
Building ♦ Driveway ♦ Fire ♦ Water Service ♦ Irrigation Meter Application
2330 McCulloch Boulevard North, Lake Havasu City, AZ 86403
Permit Center 928.453.4148 ♦ Inspections 928.855.3816 ♦ www.lhcaz.gov
Project Name Estimated Project Value
Project Address
Mailing Address (Street, City, State, Zip Code)
Project
Description
SQUARE
FOOTAGE
Block
Irrigation meter and backflow
✔
✔
click to sign
signature
click to edit
IRRIGATION METER
ADVISORY & ACKNOWLEDGEMENT
1. A
backflow prevention device (aka cross connection control device) must be installed on an
irrigation meter by a licensed plumber.
2. T
he backflow device must be tested by a certified tester prior to being placed into service and
on
a yearly basis thereafter.
3. T
he owner is responsible for all costs associated with the installation and testing of a backflow
prevention device as well as the costs to connect the irrigation system to the City install
ed
irrigation meter. These costs are paid directly to the contractors hired by the owner.
4. T
he costs associated with the installation of the irrigation meter and the monitoring of th
e
bac
kflow prevention device charged by the City and paid to the City by the owner are:
A. Irrigation Meter Installation: fees are determined by the Water Division (after application
s
ubmission) based on various determining factors. Current fees range from $500 to $4,500.
B. Bac
kflow Prevention Permit: - $191.00
C. Cross Connection Control Device Monitoring: monitoring fee, per device, is $2.83 per month
($34 annually) included in the owner’s water bill.
5. T
he rates for water flowing through an irrigation meter differ from the regular domestic water rates
(i.e., water 0 - 1,300 cf = $1.35, irrigation 0 - 1,200 cf = $1.76). However, sewer rates are not
charged for the water flowing through an irrigation meter.
6. W
ith the existence of an irrigation meter, all water rates are charged based on actual
consumption (winter quarter averaging does not apply).
I
acknowledge receipt of this Advisory and Acknowledgement and agree to abide by its provisions.
PROPERTY ADDRESS:
OWNER NAME (Please print)
OWNER SIGNATURE DATE
N
OTE:
This acknowledgement, signed by the owner, must be received by the City prior to
issuance of the backflow prevention permit and installation of the irrigation meter.
I
f you have any questions, call the Water Division at (928) 855-2618.
Additional information on rates and regulations can be found in brochures “Monthly Sewer Charge
Calculation” and “Water & Trash Rates and Regulations” which can be obtained at City Hall or on the
City’s website at lhcaz.gov
and search Water & Trash services.
Page 1 of 1 04/15/2016
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Project Address ARCHITECT OWNER Project Name Estimated Project (Lake Havasu City)

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Completed 3 August 2020

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