Permit, Inspection & Lockbox Application

2. Inspections & Permits:*
   -- Select One --Lockbox - $65.00Childcare DES/DCS - $100.00 initial /renewal license inspectionAdult Daycare (DHS) - $100.00 initial /renewal license inspectionFireworks Sales inside building (90 Day) - $150.00 Inspection / PermitResidential Care Home (Nursing, Behavioral & Assisted Living)-$150.00 Initial/renewal license Inspection

4. First Name:*

5. Last Name:*

7. Address1*

9. Address2

11. City*

12. State*

13. Zip*

15. Phone Number:*

16. Alternate Phone Number:

17. Email:

19. Subdivision or Intersection:*

21. Payment Instructions

    Please mail or hand deliver payment to:<br> <br> City of Surprise<br> Attention: Revenue Division<br> 16000 N. Civic Center Plaza<br> Surprise, AZ 85374-7470<br> <br> <strong>Note:</strong> As soon as payment is received, a representative from the Fire Medical Department will contact you to schedule an appointment.

    Please mail or hand deliver payment to:
    
    City of Surprise
    Attention: Revenue Division
    16000 N. Civic Center Plaza
    Surprise, AZ 85374-7470
    
    Note: As soon as payment is received, a representative from the Fire Medical Department will contact you to schedule an appointment.

23. Scheduled Inspection Date:
    Scheduled Inspection Date:

24. Start Time:
    Start Time:

25. End Time:
    End Time:

27. Inspection/Permit Approved Date:
    Inspection/Permit Approved Date:

28. Request Status
    -- Select One --PendingComplete

Leave This Blank:


29. Print Only

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