HomeMy WebLinkAbout1408 Pitkin St - Applications/Electrical - 10/14/2011City of Planning, Development & Transportation
Fort N. College Ave P.O. Box 580
F®rt Collinst 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- p 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 # �Date s0
For office use only
Job Site Address (required) Value of Construction (labor, materials,. profit)
N0 ; +-k,)./ s 1� 4 o0
Property Owner Name Address
City/State Zip
Phone
N
Applicant Name Address
City/State Zip
Phone,
1Lu,k Rv In tA.k 700' 10 o
s F'T o 5a
1 69 - 3655
Contractor Lic # Address
City/State Zip
Phone
Sr a rr M E- y oo
Sr -FT.- o
-
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
sales tax number isrequiredbyall contractors.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or �9mmercial project? [V 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 (explai )
Is this building 50 years of age or more? ❑ Yes INo If yes, you may need to contact Historic Preservation
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.
*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 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:.- IALtc-ate UNI'LI. � Signature L - Date