Transcription of PINAL COUNTY BUILDING SAFETY
1 PINAL COUNTY community DEVELOPMENT BUILDING SAFETY DIVISION 31 N. PINAL ST. BLDG. F, FLORENCE, AZ 85132/520-866-6405 SOLAR/MPE APPLICATION TYPE OF APPLICATION: COMMERCIAL_____ MECH_____ PLUMB_____ ELEC_____SOLAR_____ PARCEL_____ STREET ADDRESS: _____CITY/STATE/ZIP_____ PROPERTY OWNER (S) _____ADDRESS_____ CITY/STATE/ZIP_____PHONE#_____ RENTER/TENANT (S) _____ADDRESS_____ CITY/STATE/ZIP_____PHONE#_____ CONTRACTOR _____ADDRESS_____ CITY/STATE/ZIP_____PHONE _____ LICENSE/CLASS #_____ CLASS OF WORK: (Check one:) NEW (or) REPAIR # OF AMPS _____ # OF BTU S_____LENGTH OF RUN _____ SIZE OF PIPE _____ TYPE OF PIPE _____ # OF KW (PHOTOVOLTAIC SYSTEMS) _____ Type of system.
2 Check one: Roof Mount Ground Mount #OF LIGHTS_____ TOTAL LUMENS_____ MAX HEIGHT_____ UTILITY COMPANY (check one): MESA GAS_____ SWG_____ SRP_____ APS_____ ED2_____ ED3_____ ED4_____ BIA_____ TRICO_____ LPG____ WELL REGISTRATION# (If applicable) _____ EXISTING USE: _____ PROPOSED USE: _____ DISTRICT OFFICE WHERE YOU WANT TO PICK UP PERMIT: FL CG AJ OR _____ CONTACT PERSON (WHO DO WE CONTACT WHEN PERMIT IS READY FOR PICKUP AND/OR QUESTIONS?): NAME _____ PHONE _____ EMAIL_____ I UNDERSTAND THAT APPROVAL OF THIS APPLICATION DOES NOT GUARANTEE APPROVAL OF THE ACTUAL CONSTRUCTION. I HEREBY CERTIFY THAT THE INFORMATION ON THIS APPLICATION AND ALL RELATED SUBMITTALS ARE TRUE AND CORRECT. _____ _____ _____ PRINT NAME PLEASE SIGNATURE OF OWNER/ AGENT DATE OF APPLICATION FOR OFFICE USE ONLY ADDRESS: YES NO SUBMITTAL FEE:_____ ZONING FEE:_____ PLAN REVIEW FEE:_____ ADDRESS FEE: _____ PERMIT FEES: _____ REVISED: June 2016 ECD.
3 _____ BUILDING Permit # community DEVELOPMENT 31 North PINAL Street, BUILDING F, PO Box 2973, Florence, AZ 85132 T 520-866-6442 FREE 888-431-1311 F 520-866-6530 PROPERTY OWNER/AGENT AUTHORIZATION FORM I (property owner) hereby authorize (owner s agent) To make applic ation to PINAL COUNTY for the following (description of work) Assessor Parcel Number: Name of RV/PM/MH Park (if applicable): Lot or Space # (if applicable): Physical Address: City/Town: State: AZ Zip: By signing this Form, I acknowledge and agree that I am not released from responsibility for: (1) the payment of any and all fees associated with the issuance of any permits, orders, notices or other approvals ( Approvals ) by PINAL COUNTY pursuant to my agent s application; (2) the satisfactory completion of all work authorized by such Approvals in compliance with all applicable COUNTY , state and federal laws, codes, rules, regulations and requirements; and (3) correcting any violations of the terms and conditions of such Approvals issued by PINAL COUNTY pursuant to my agent s application.
4 Property Owner: By (signature): Name: Title: Phone Number: Email: Date.
