Environmental Responsibility And Certification Form - City Of Phoenix, Planning & Development Department
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1Environmental Responsibility and Certification
For Projects Constructed by Private Developers
(Plan Submittal)
Project Name: _______________________________________
Project No.: ___________________________
Project Address: _____________________________________________________________________________
City: _______________________________________________
State: ______ Zip Code: ________________
Quarter Section: ___________
APN: ____________________________
Acreage: ____________________
Project Description: __________________________________________________________________________
Property Owner Name: _____________________________________ Phone No.: _______________________
Mailing Address: ________________________
City: ___________________ St.: ____
Zip Code: ______
Architect/Engineer of Record Name: ___________________________________ Phone No.: _______________
Mailing Address: ________________________
City: ___________________ St.: ____
Zip Code: ______
License # (if applicable): ______________________________________________________________________
General Contractor Name: __________________________________________ Phone No.: _______________
Mailing Address: ________________________
City: ___________________ St.: ____
Zip Code: ______
License #: _________________________________________________________________________________
------------------------------------------------------------------------------------
Environmental Responsibility Acknowledgement and Certification
As the property owner, or an agent authorized by the property owner, I acknowledge and understand that this
project and the activities related to this project may be subject to county, state, tribal and Federal environmental,
natural and cultural resource rules and laws including, but not limited to, those regarding:
Air Quality / Dust Control
Clean Water Act (NPDES, Section 404, Water Quality
Archaeological / Cultural /
Comprehensive Environmental Response Compensation and Liability
Historic Resources
Act (CERCLA, superfund)
Asbestos / Lead Abatement Act
County Environmental health (Septic Systems, Wells, Water /
Endangered Species
Wastewater, Vector Control)
Hazardous Substances
Resource Conservation and Recovery Act (Hazardous Waste)
In addition, as the property owner, or as an agent authorized by the property owner, I hereby certify that all
County, State, Tribal and Federal permits applicable to this project will be obtained, and all requirements or
conditions of such permits and all environmental laws will be complied with to the best of my knowledge. NOTE:
This certification must be completed, notarized, and submitted to the city of Phoenix Planning and
Development Department before plans or permits may be approved for any part of this project. Use or
occupancy of any part of this project without final approval from the city of Phoenix is a violation of the
Phoenix City Code.
Owner /
Authorized Agent _______________________________________________________________
Name (printed)
____________________________________________________
___________________________________
Signature
Date
Acknowledged before me this ____ Day of ________________________, 20____
___________________________
__________________________________
My Commission Expires:
Notary Public:
This publication can be made available in alternate formats (Braille, large print or digital media) upon request.
Contact Planning & Development at (602) 262-7811 voice or (602) 534-5500 TTY.
S:\Environmental Responsibility, Submittal
TRT/DOC/00412
Rev. 12/12
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