HomeMy WebLinkAbout1107 Mathews St - Applications/Electrical - 05/20/2013Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, C0180524
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 # Dt 3&2533 Date 5 13
For office use only
706
Site Address (required)
Value of ConstUction (labor, materials, profit)
0,0
$
Pr
�perty Owner Name Address
City/State Zip
Phone
Vr,
L cal a
X- 9 -3 43
Applicant Name Address
City/State I Zip
Phone
LJ C I1410
W&3lr_cAve. ►1=a.CalIiAsGO 8'DroZ�f 9b=ff9t!-5
Contractor Lic # Address City/State I Zip
11pc-'S Be,:�riC, ME=131 ►yIDWeoSterAve, _�,CoU;f_J5Jc0 S!)52e4
Phone
Q70-48q-5-08.5
Contractor
Sa%s
City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
D1 Here ❑ Report
tax number isrepuiredbyall contractors
2143'7
Are you paying with your trust account?
❑ Yes No
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: )X 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 .
:__....<.... �-_::.:.-:= -. .._ .:❑'iE.='t`dliraS3t.:_:: ,. � e..7�i.a.=. ...._ _.. _ __._.....
Is
If
If
building 50 years of age or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preservation
Is for a demolition permit, what year was the building constructed?
r to 1975, you will need an asbestos assessment to submit with this application.
of work
lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
List the company name or city of Ft Coffins license #
i
Plumber Mechanical Roofer Other
( acknowledge that I have read this application and state that the above information is complete and correct. I agree to
with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
is not valid until it has been paid and issued.
Name:
Date ��