Maricopa

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Change Certificate Application

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Contact Person *

Title *

Email *

Company Name *

Phone *

Ext.

Fax Number *

Address *

City *

State *

Zip Code *

Please Mark the Appropriate Box Below

Change Project Name

Change Project Owner Name

Fee - $200.00 per certificate

 This form to be used when changing either the Project Name or Owner Name on a previously approved subdivision. (May also be used for other projects only if deemed by the SIPP Staff.)  Provide supporting documentation verifying/confirming the change: Warranty Deed, Amended Plat, correspondence, etc.  Provide the OLD/current information including issued MCESD number and NEW/requested information in the spaces provided. MCESD will then provide new numbers.  Project Owner / Responsible Party must sign the application. This person must be a person with fiduciary responsibilities associated with the Project or Company.  Provide a copy of previously issued certificate with corrections indicated also.  The fee is $200 Per Certificate. If a project has both Project Name Change AND Owner Change, the fee is $200 if submitted at same time.

OLD Project Name *

MCESD # *

NEW Project Name *

MCESD # *

OLD Project Owner *

Job Title *

MCESD # *

NEW Project Owner *

Job Title *

MCESD # *

Owner must be a PERSON with fiduciary responsibilities associated with the Company.

Project Owner Name *

Project Company Name *

Project Company Mailing Address *

City *

State *

Zip Code *

Phone *

Ext. *

Fax *

Email *

The Project Owner hereby authorizes the review of project plans as described for approval to construct and/or provisional verification of conformance under General Aquifer Protection Permit 4.01.

Created by AIPSS

Maricopa

Change Certificate Application

Project Details

Change Project Name

Change Project Owner

Project Owner Information

Authorization