HomeMy WebLinkAbout2501 Midpoint Dr - Applications/Electrical - 10/20/2011Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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 # b k \' o � -3i$ Date /%0zll
For office, use only �
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name
Address City/State Zip Phone
Applicant Name
Address City/State Zip Phone
lee o_-.- 4 crk Ac
3.?w .4n&o 42 '1ab5?'F g-7oG69;;Jk2i
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? ❑ Residential ❑ Commercial
If residential, is it: ❑ 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. ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you will need an asbestos assessment to submit with this application.
Description of work cflaa?,elc / .9401?VoXl 70 Sff/ce
sel?ylC,e. 'ee111J1toS
*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 #
Electrician/%JE 4-'Ou 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. -I /N�StP�^�S�/' Signatur �,� Date �� //