Town Of Quartzsite P.O. Box 2812/465 N Plymouth Ave., Quartzsite, Az. 85346
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Owners Name and Business Name (if Applicable): _________________________________________________________
Phone #: (___)_______________ Fax#: (___)____________________ Cell Phone #: (___)_________________________
Address: (number, street, city, state, zip) _______________________________________Email: ____________________
Site Address:____________________________________________________ Parcel No.: ________________________ |
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Contractor: _____________________________________Contact Name: ______________________________________
Phone #: (___ )__________________ Fax#: (___ )_______________________ Cell Phone #: (___ )__________________
Address: (number, street, city, state, zip)________________________________________ Email: ___________________
AZ Contractor License#: ______________Type: ______________City License #: __________Sales Tax #:____________
AZ Architect/Engineer of Record: _____________________________Contact Name: ____________________________
Phone #: (___ ) __________________Fax#: (___ )______________________ Cell Phone #: (___ )__________________
Address: (number, street, city, state, zip)________________________________________ Email: ___________________
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Proposed Use___________________________ Type of Work ______________________________
(Residential, Commercial, Other) (New, Repair, Alteration, Other
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Plumbing ___# of Fixtures, Traps, Sets/Traps ___# of RV Water Taps ___# water heater and/or vent ___Install, Alter or Repair Water Pipe ___Install, Alter or Repair Gas Pipe ___Industrial Waste Pre-Treatment ___Alter or Repair of Drain or Vent Piping ___Lawn Sprinkler System/Meter ___# of Blding or Trler Sewer Taps ___#RV Sewer Traps ___Atmospheric Type Vacuum Breakers ___Backflow Protective Device Other than Atmospheric ___Graywater System Other ______________________ . |
Electrical ___# of Service Entrances Less Than 200 Amp ___# of Service Entrances More Than 200 Amp ___Total # of Branch Circuits ___RV Pedestals ___# of Private Swimming Pools ___Temporary Service Entrance ___Temporary Holiday Lighting ___# of Receptacles, Switches & Light Outlets ___# of Light Fixtures ___# of Residential Appliances ___# of Nonresidential Appliances ___# Power Apparatus Rating HP ___# of Busways ___Sign first 660 VA’s= ___Additional 660 Sign VA’s= Other_____________________ . |
Mechanical ___Furnaces ___Appliance Vents ___Repairs or Additions to ___heating, refrigeration, ___cooling absorption system ___Boilers, Compressors and ___Absorption Systems ___Air Handlers ___Evaporative Coolers ___Ventilation and Exhaust ___Incinerators Other __________________. |
[ ] I certify I am currently licensed under the provisions of the Arizona Registrar of Contractors for the work.
[ ] I am the owner of this property and I am doing my own work.
[ ] I am exempt from the provisions of the Arizona Registrar of Contractor’s regulations.
INSPECTIONS ARE REQUIRED PRIOR TO CONCEALMENT
Signature___________________________________________________ Date_____________________________
Receipt Number ______ Check No. ________ Amount _____________Date__________ Rec’d By_____________
Zoning Approval ___________________________________ Building Official______________________________