HomeMy WebLinkAbout2413 W Stuart St - Applications/Electrical - 03/13/2012City of
Fort 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 afor 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 O Lawn Sprinkler bile 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 # 13un Date
For office use only I G,
Job Site Address (required) Value of Construction (labor, materials, profit)
W . S-I-i, cc�I+
Property Owner Name Address
City/State
Zip
Phone
_ea1C/\ ro C
770-
Nam
Applicant Address
City/State
Zip
Phone
c w c2:5 ,5-CadCI°4t
5d-, Love larld 12 -
90i3l
720
Contractor ME-ja! ( Lic # 70F$ Address
City/State
Zip
Phone
V,,_4ef56n s" ZS5_ CAlc5- k- Z-01e1600) Co,
n53-7W-A/. FAD
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here )4 Report
Sales tax number is required by allmntractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial 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 (explain)
Is this building 50 years of age or more? ❑ Yes ❑ 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.
of work
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e vkc c
*If lawn sprinkler/backFlow preventer, m 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: Cl 05k t l A Q • �P �P� W Signature
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60
(C)