HomeMy WebLinkAbout1406 Ash Dr - Applications/Electrical - 04/11/2013CityOf Planning, Development & Transportation
281 N. College Ave P.O. Box 580
F6r } ` Collinsi IFort Collins, CO 80524
`.- Phone 970-416-2740 Fax 224-6134 �a
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) Ef 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 # / ? A l � Date PsP g-A i _ 1 l � Zo i F,
Fnr n ira nea only
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Address (required) TValue of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State
Zip
Phone
FT -(MN ZaGe?- 140(a
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Applicant Name
Address
City/State
Zip
Phone
KIKbfN Sl\UA if 140e
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Contractor Lic #
Address
City/State
Zip
Phone
Contractor City of Ft. Collins Sales Tax
#
Are you paying taxes here or by report?
❑ Here ❑ Report
Sa/es tax number is required by all contractors.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? L9 Residential ❑ Commercial
If residential, is it: IgSingle 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 50 years of age or more? ❑ Yes ErNo If yes, you may need to contact 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 U?6RA;NL)�X 5F"NA
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*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 #
1394 ani
Electrician 2El.Cae3t° 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: �/ C
Print Name: i���S� GkQk 6_ Signature
Dat4 1/-2113