HomeMy WebLinkAbout3601 Rock Creek Dr - Applications/Electrical - 02/12/2013Jan 30 13 04:31 p Eggers Electric Inc
970-669-0476 p.4
Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
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) O 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. Incomplete alipl�icaattiojns will not be accepted.
Application # S O 6T Date 4 - - A;�
For offxr use only. t ^ J
Job Site Address (required
alue of Construction (labor, materials, profit)
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c
lPr perry Owner Name Address
I V�
City/State Zip
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Phon%c i t l
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone c)'70
a5330
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ntyof Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here ❑ Report
Sales t"number isfWwredbya/lccntradnrs
Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or commercial project? ["Residential ❑ Commercial
If residential, is it: ❑� 9le Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
131Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank' ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? D Yes ❑ No Ifyes, you may need to mntactHrstbric Preservation
If this is for a demolition permit, what year was the building constructed? n 19
If pnor to 1975, you will need an asbestos assessment to submit with this application.
Of
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Su bcontra cto rs: List the company name or City of Ft Collins license #
Elecbiaar� Plumber Mechanical RQoFer tithe
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: r
Print Name gnature Date
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