HomeMy WebLinkAbout1611 S College Ave - Applications/Electrical - 04/11/2013City Of Planning, Development & Transportation
Fry 281 N. College Ave P.O. Box 580
or t 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. Incomplete applications will not be accepted.
Application # WO 169« Date
For offlce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
16d 6,$ -3
Property Owner Name Address
City/State Zip
Phone
Applicant Name Address
City/State Zip
Phone
2 i /`%
/
� CO`�i
Contractor Lic # Address
City/State Zip
Phone
735 Zle 4,' L - 33 5r,-
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here KReport
sales tax number isrequiredbyall contracYors
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
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/M4tel ❑ Me 'cal office ❑ Office ❑ Retail
Restaurant ❑ Other (explain) 6 V Sol& Qf(wQ
Is this building 50 years of age or more? ❑ Yes Pg,,No If yes, you may need to c ntact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*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 #
Electriaan /yIL- S 3 3 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 h s been paid and issued.
Applicant: // //
Print Name: Signature _t? �4& n Date