Redidential Commercial Industrial (check one)

Owner Builder Contractor (check one)

Project / siteaddress Lot # Subdivision

Zoning Parcel # Lot Area (sq. ft.)

Lot Setbacks Front Back Side Side

APPLICANT

Applicant Renter Lessee      Phone # A value is required.Invalid format.

Mailing Address City State Zip A value is required.Invalid format.

PROPERTY OWNER INFO

Name Phone #

Mailing Addresss City State Zip

Property Owner signature __________________________________________

CONTRACTOR

Contractor Contact Person

Mailing Address City State Zip

Phone Cell Fax

Town of Quartzsite License # Az License # Class

Az Architect/Engineer Contact Person

Mailing Address City State Zip

Occupancy Type:

Assembly Business Education Hazardous Utility Factory-Industrial Institutional Mercantile Residential

Storage      Business Type

Type of Work: New Construction Patio Cover Re-roof Re-model

Addition Repair Other

Proposed Construction(Be Explicit)

Construction Type: Wood Metal Masonry Other

Building Length Building Width Building Height     

Septic Tank Yes No (must have copy of La Paz County Health Department Approval) Well Water Town Water System

Attachments Plot Plan Foundation Plan Structural Section Exterior Elevation Floor Plan

I certify that I have read this application and state that the information is correct. I agree to comply with all Town and County ordinances and State Laws relating to building construction, and hereby authorise representatives of this Town to enter upon the above-mentioned property for inspection purposes.

Signature of Applicant:_________________________________________ Date:________________________________

Owner Contractor Agent

ACCEPTANCE OF APPLICATION IS NOT AN APPROVAL TO CONSTRUCT

OFFICE USE ONLY

Zoned Flood Plain Is an Elevation Certificate Required Yes No    

  Zoning Approval

Fees: BLDG Plan Check Mech. Other Total

Receipt Number Amount Date Rec'd
Authorised Town Official