HomeMy WebLinkAbout701 Rochelle Cir - Applications/Electrical - 09/13/2011Planning; Development & Transportation
CityOf 281 N. College Ave P.O. Box 580
F6rt 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). 0 Air Conditioning
❑ Demolition (interior non-structural) 0 Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation 0 Water Heater ❑Water Line 0 Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applica a information on the application. Incomplete applications will not be accepts
AN'ficat!
n # 1�� l� Date !✓� o�O�--
Foy ofte use onty.
lob Site Address (required) Value of Construction (labor, materials, profit) —7
Q�2 C r'c o. $ 1 /-/'R,�0
Property Owner Name
Address
City/State
Zip
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Applicant Name
Address
City/State
Zip
Phone.
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Contractor Uc #
Address
City/State
Zip
Phone
1
-
Contractor City of FL Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
Safes tax number isregi&edbyaifcmnbacmis
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
0 Multifamily (apartment) ❑ Garage
If commercial, is it: 17 Hank D Bar i 3 Church ❑ Hotel/Motel ❑ Medical office 13 Office ❑ Retail
17 Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yeses No If ye4 you may need to contact Histonc kis erYabbn
If this is for a demolition permit, what year was the. building constructed? h - - - -- - -- _
if prior to 1975, you coif/need an ads asw-;wment to submit wiffi tfiis applicair'on.
of work
*If lawn sprinkler/bacidlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty of ft Coffins license #
Bechidan _ 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 r 'feting building construction. I know that a
permit is not valid until it has been paid and issued.
Applicarrlt:
Print Name: Signature Date I' 1 3/ l%