Residential Commercial Industrial (check one)
Owner Builder Contractor (check one)
Project/Site Address
Lot # Subdivision Zoning Parcel #
Lot Area (sq. ft.) Lot Setbacks: Front Back Side Side
Applicant Renter Lessee (check one) Phone #
Mailing Address City State Zip
Property Owner Phone #
Property Owner Signature
Contractor Contact Name Email
Phone # Cell # Fax #
Az Lic. # Class Town of Quartzsite Lic. #
Az. Architect/Engineer Contact Name Lic. #
Phone #
Occupancy Type: Assembly Business Education Hazardous Utility Factory- Industrial Institutional
Mercentile 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 Masonry Metal Other
Project Valuation $
Building Length Width 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 authorize representatives of this Town to enter upon the above-mentioned property for inspection purposes
Applicant Signature Date
Owner Contractor Agent
Office Use Only
Zoned Flood Plain Is Elevation Certificate Required yes No Zoning Approval
Fees: Building Plan Check Mech. Other Total
Receipt # Amount Date Rec'd Authorized Town Official
Town Of Quartzsite Town Of Quartzsite