Form Udm-075 - Building Permit Application Form
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1
2City Permit No.
Building Permit
Application
Applicant/Applicant’s Representative (contact for questions, plan pickup, etc.)
Date
Phone Number
E-Mail Address (Optional)
Trust Account:
Trust Account Number
Yes
No
Permit Type:
Commercial:
Residential:
Other:
Site Plan
Custom
Standard Plan
Pool/Spa
No.: ____________
Tenant Improvement
Remodel
Gas/Elect
Elevation: _______
Water Meter
Project Address
City, State, Zip
Project Name
Description of work to be performed
Construction Area S.F.
Pool S.F. (pool permit)
Type of Construction (e.g. I, II, III, IV, V)
No. of Stories
Occupancy Class
Assessor's Parcel No.
Subdivision/Shopping Center Name
Lot No.
Property Owner Name
Phone Number
Fax Number
Mailing Address
City, State, Zip Code
Contractor Name (Please Sign Below)
City Sales Tax No.
Phone Number
Fax Number
Mailing Address
City, State, Zip Code
Water Meter is:
Domestic Meter Size
Landscape Meter Size
Service Line Size
New
Inside City Limits
Existing
Outside City Limits
Name
Phone Number
Billing Address
City, State, Zip Code
Applicant/Applicant’s Representative/Owner’s Signature
Date
Total Construction Valuation (bid price, if applicable):
I am Currently a Licensed Contractor: (This section must be filled out by contractor or have a qualifying exemption)
Falsification of information on this
________________________
Name:
document for the purpose of evading
ROC License #:____________________
State Licensing laws is a Class II
License Class: ___________________
Signature: __________________________
misdemeanor pursuant to A.R.S. State
I am claiming an Exemption
Statutes 13-2704. See back of this form
for state statue regarding contractor
(See back)
Date:
___________________________
licensure and exemptions.
Transportation and Development Department
Mailing Address:
Telephone: (480) 782-3000
Development Services Division
P.O. Box 4008, MS 406
Fax: (480) 782-3055
215 E. Buffalo St., Chandler Arizona 85225
Chandler, Arizona 85244-4008
Form No: UDM-075/Building
Rev: 6-17-11
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Parent category: Business