Utility Permit Extension
Request Form

Fax request to 623-773-7211, Attn: Permit Specialists



UTILITY COMPANY:  										


PERMIT EXTENSION REQUEST #1

PEORIA PERMIT NO:  				  LOCATION:  					
REASON FOR EXTENSION:  										
													
EXPECTED DATE OF COMPLETION:  								
CONTACT NAME:  						  PHONE: 				
E-MAIL:  							  FAX:  					

PERMIT EXTENSION REQUEST #2

PEORIA PERMIT NO:  				  LOCATION:  					
REASON FOR EXTENSION:  										
													
EXPECTED DATE OF COMPLETION:  								
CONTACT NAME:  						  PHONE: 				
E-MAIL:  							  FAX:  					

PERMIT EXTENSION REQUEST #3

PEORIA PERMIT NO:  				  LOCATION:  					
REASON FOR EXTENSION:  										
													
EXPECTED DATE OF COMPLETION:  								
CONTACT NAME:  						  PHONE: 				
E-MAIL:  							  FAX:  					

													


APPLICANT PRINTED NAME	         DATE	         APPLICANT SIGNATURE




					
Revised on 12/08/04