HomeMy WebLinkAbout1412 Luke St - Applications/Electrical - 02/13/2012City Of Planning, Development & Transportation
Fy{} R , 281 N. College Ave P.O. Box 580
t� Co�, ns Fort Collins, CO 80524
Phone 970-416-2740 Fax 22"im
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 ❑ 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 #_ _ ]/ lzoo Date a1�:5
Far office use only
lob Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name
Address
City/State Zip
Phone
Applicant Name
Address
City/State Zip
Phone
Contractor
Address
City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax ht
Are you paying taxes here or by report?
q Here ❑ Report
salesbxnumbergrequkWbya0cnnbacbm
Are you paying with your mist account?
❑ Yes ❑ No
Is this a residential or eommerdal project? gResidentiai ❑ Commerdal
If residential, is it: OSingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartrnent) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
. ❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes ❑ No If yes, you may need to contact H/staric Preservation
If this is for a demolition permit, what year was the building conducted?
Ifpnor to 1975, you wi// need an asbestos arse nt to submit with this application.
Description of work _1/f -t
*If lawn sprinkler/baWow preventer, must list licensed plumber. If first-time AfC, must list licensed electrician.
Subcontractors: List the company name or C72y of Ft a irzs /rcais e #
Electrician Rumba Medianical Roofer r--- other
I hereby admowledge 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:Signature Date