HomeMy WebLinkAbout1204 W Oak St - Applications/Electrical - 11/07/2011Fort 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) ;K 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 appli a le i('V formation on the application. Incomplete applications will not be accepted.
tion Applica# � 1 1 9D Date ►I �7 III
For o1�ce use only /Jd • D
Sob Site Address (required) Value of Construction (labor, materials, profit)
I ?,O H VJ. o A-Y- s'(. $ Zarb, oo
Property Owner Name Address
City/State Zip
Phone q Z 0
11 Ay (z . ti(t,\/L LL — SAT
170 w, o41C J'(. F-r c ou, NS (,a
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Applicant Name Address
City/State Zip
Phone
5(o-T L( t� s
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Contractor Lic # Address
City/State Zip
Phone
tsYjA14*,R,MC 3 1
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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 c mmercial project? IN 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? XYes ❑ No If yes, you mayneed 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.
Description of work
WN
*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: 5W i ri Signature
Date 11 b 1