HomeMy WebLinkAbout1601 E Pitkin St - Applications/Electrical - 01/24/2012Fort 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 PERMITSONLY
This application is to be used to apply for the following permits only (check all tlat 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 O Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application # ,...
Incomplete applications will not be accepted.
Date 14 - l
For oince use only 61 O (7o 4-1 a I v—
Job Site Address (required) Value of Construction (labor, materials, profit)
D I �; ��; 51 yo o. o0
Property Owner Name Address
City/State Zip
Phone
Applicant Name Address
City/State Zip
Phone'
l-mk 00 Oood
ST FT 05 a
1 69 - 5
Contractor Lic # Address
City/State Zip
Phone
13r a 1' M E-
oo S -F"r ra 205,21
-7Q 1/4
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 c9mmercial project? M Residential ❑ Commercial
If residential, is it: F1 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 SO years of age or more? ❑ Yes Eff 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 w/l/ need an asbestos assessment to submit with this application.
Description of work
CG'+y o 4 Ff.
r
*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:- bli�_./� /
� �Nl'K. � UU Signature � �✓lDate