HomeMy WebLinkAbout805 Cheyenne Dr - Applications/Electrical - 09/27/2011Planning, Development & Transportation
City, of 281. N. College Ave P.O. Box 580
Flirt 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). E3 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 0 Photo -voltaic
• Ventilation ❑ Water Heater 0 Water Line 0 Wood/Pellet Stove (must. be EPA certified, provide make,'model and
manufacturer).
Complete all applicable information on the application. lncomplete applications will not be accepted.
Application # - n % Il/ 2 Date la'1 [ t
For office use only
Job Site. Address (required) Value.of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone
C-k+EK1C/uE
OR�
L
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Applicant Name Address
City/State Zip
Phone
IZEGa Ec6r rL i L 33117 /J. 44A4C.,,-, AW- Z-ca+e um Cv 80S3S
(o` .7&dF
Contractor Uc # Address
City/State Zp
Phone
Contractor City of Ft. Collins. Sales Tax #
Are you paying taxes here or by report?.
p Here A Report
Sales twr number is wuired by all contactors
Are you paying with your trust account?
❑ Yes 9 No
Is this a residential or commercial project? O.Residential 0 Commercial
If residential, is it; M Single Family Detached ❑ Condo/townhome (single family attached) _ ❑ Duplex
0 Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office [3 Retail
0 Restaurant ❑ Other (explain)
Is this building 50 yearn of age or more? C]Yes ®No If yes, you may need to contact Hlslnric Preservabbn
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 appiicabon.
Description dwork _RLkAaT- F%0cRAA- PAuFta 97CAC-MC&C- P,N+ec_ i gZ4woc,6-lit J5tA3A1
sST74��wEcL �n/R>_:.�OSEotir.�i.' /Nsjjo.ct_ S7�A� Ctec..�.rs lw+Ta i9-Tr�c SP•o.�{ Fq�Z �tl+tl� K�rr�N
*If lawn sprinkler/bacidlow preventer, must fist licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the cvmparry name or Gty of Ft Collins license #
Electrician 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:
Print Name: A+n s-s signature
Date