HomeMy WebLinkAbout625 W Mulberry St - Applications/Electrical - 11/10/2011City Of Planning, Development & Transportation
Fort Collins Fort N. College Ave P.O. Box 580
. Collins, CO 80524
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A Do ebb Phone 970-416-2740 Fax 224-6134
OVER -THEN -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) FElectrical 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 wi I not be accepted.
Application # Y7 t t � lu�>2_n ,Date (/ o
For oince use only
Job Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State
Zip
Phone
P& eCk
Applicant Name Address
City/State
Zip
Phone
1`y -- oGG:'-_ tc
Contractor Lic # Address
City/State
Zip
Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? I7Here ❑ Report
Sales tax number is required by all contractors.
Are you paying with your
trust account? ❑ Yes `,R No
Is this a residential or commercial project? 0,-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? AYes ❑ No 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.
Description of work (� PDA-a DF:5-0( cFs , (,,rCa4 7-5,
97cC 12c 04-t-'172&eaY-5 L
*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: r
Print Name: /`ter r l ' `"-aSignatureG� Date / L/,