HomeMy WebLinkAbout216 Linda Ln - Applications/Electrical - 03/05/2013City Of
�� t 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) ❑ 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 applicatbns will not be accepted.
Application # -Z)0 10 r-1 Date 3- S - /3
F r ice use only
Job Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name_
Address
City/State
Zip
Phone .
Applicant Name
Address
City/State
Zip
Phone'
Ceske .vrKk. 700
Wooct Sr Fr. co /;.�1.s 80,5.z
1
69,2 -3 55
Contractor Lic #
Address
City/State
'Zip
Phone
far o_,, Ga-rreii' MI- -1;?H9
?35
A)ood S Ft• eo//.'.vs
BoS-q1 566- 7016
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
.Sales tax numberls required by all contractors.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? 6if Residential ❑ Commercial
If residential, is it: 'O'Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (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 M No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructe6
d?
If prior to 1975with , you will need an asbestos assessment to submit 'tl is application.
Description of work Reloc-L,+e niev2 r1cefr','c Me-fer -L-S 1per-} of
Zthc C / e742 Ffi Co11:'v5 ANNL'�r0.fOn/ aN� u�a/ de _P/Yeciacf5
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
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.
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Applicant: LwG Linfw:�
Print Name: k /SignaturedtAk aX4tik Date --