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Utilities, Conditional Clearance Request-Agreement

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To request a conditional utility clearance, the owner or owner agent shall complete this form and provide a copy to the area inspector or Field Supervisor for permanent records. The required fee shall be paid via the phone at (602) 262-7811 or at the Development Center, Payments and Submittals Counter, 200 W. Washington Street, 2nd Floor, Phoenix, Arizona 85003.

The owner understands, promises and agrees with the following conditions:

1. The gas or electricity service SHALL NOT be used to serve the building for other than (1) temporary connection for testing or construction purposes; or (2) limited occupancy approval.

2. All required special inspections and observations shall be performed and all documentation shall be submitted to the Building Official for review prior to issuance of a final or certificate of occupancy.

3. A recognized lockout/tagout procedure shall be in place and utilized as necessary.

4. An application fee (see Phoenix City Code, Appendix A.2: (Temporary Utility Clearances) shall be paid and a copy of this document shall be posted with the permit.

5. The premises SHALL NOT be utilized or occupied without first having obtained a Temporary Certificate of Occupancy (TCO), or other required approvals from the Building Official.

6. Other stipulations:

7. IF FOR ANY REASON THE ABOVE NOTED ITEMS ARE NOT COMPLIED WITH, THE AFFECTED SERVICE EQUIPMENT SHALL IMMEDIATELY BE REMOVED FROM SERVICE.

8. If the city of Phoenix orders the service equipment to be disconnected for failure to comply with the terms of this agreement, the owner hereby holds harmless and indemnifies the city of Phoenix.

The following information shall be completed by

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Created by AIPSS