HomeMy WebLinkAbout764 Eastdale Dr - Applications/Electrical - 11/18/2013City of
FF �,rt 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 anu
manufacturer). dri
Complete all applicable information on the application. Incomplete applications will not be accepted. O
Application # ?21 so(10ffi Date 114113
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name
Address
City/State Zip
Phone
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Applicant Name
Address
City/State Zip
Phone
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Contractor
Address
City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?,[&Here
❑ Report
Sales tax number is required by all contractors.
Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or commercial project?
If residential, is it:
,Residential ❑ Commercial
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 50 years of age or more? ❑ Yes Z No If yes, you may need to contact Historic Preservatio
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
of work
*If lawn sprinkler/backflow preventer,'must list
Subcontractors: List the company name or City of Ft Collins license #
Electrician
A/C, must list licensed electrician.
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: ` � �- / q�
Print Name: / ' 9,Signature Date