HomeMy WebLinkAbout208 S Shields St - Applications/Electrical - 07/12/2012City. Planning, Development & Transportation
�tY of 281 N. College Ave P.O. Box 580
�rt Collins Fort Collins, CO 80524
\., Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter. ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application # A `/'9-3 o
For office use only
Incomplete applications will not be accepted.
Date
Job Site Address (required) Value/ of Construction (labor, materials, profit)
02 S - �S/Af/c oS $ 46,Dc, =
Property Owner Name Address
City/State Zip
Phone
/IlLf,L AJ /��c-M
Applicant Name Address
City/State Zip
Phone
Contractor Lic # Address
City/State Zip
Phone
/UCarl-l' 33117 /J. Cz coLa R..v- "QLLA,,O
G,(�9-76c
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here aReport
Sales tax number isrequired byall contractors
Are you paying with your trust account?
❑ Yes :] No
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
k"ultifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain).
Is this building SO years of age or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work 6/P,1R.aoL, 10,ku r', ui6-r_ T� p26o/iMA, /1,0.0 CL46r7LiC� 138 Herr "
/� Qg36rr F o T 4- a41L,'6L Ge. ,, i M SC £L�C,—rUG4L /ZFP�3 2j
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.'t
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber Mechanical Roofer
Other
I hereby acknowledge that I have read this application and state that the above information is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant:,
Print Name:-��s Signature
Date
7/,2/" Z_