HomeMy WebLinkAbout1400 Emigh St - Applications/Electrical - 04/16/2012Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, OD 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) ❑ 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 # lb la Oo1a'9 Date y�/d`
For office use only F.
Sob Site Address (required)
Value of Conshvction (labor, matutals, profit)
Property Owner Name
Address
City/State Zip
Phone
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% i Wit.
Applicant Name
Address
City/State Zi
?h one
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/ir I C Ito ��
Contractor
Address
City/State Zap
Phone
/
ai
Contractor City of FL Collins Sales Tax #
Are you paying taxes here or by report?
0 Here ❑ report
Saks taynunfisrequiredbyaff aizftdom
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? - g Residential ❑ Commercial
If residential, is it ITSingle Family Detached ❑ Gondo/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 cantart Hbtadc Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you w/// need an asbestos a-zessrnentto submit w/th tb/s apprAcaft rx
Description of work �1
*If lawn slxinider/baddiow pr, ven et, must list licensed plumber. If first -tune A/C, must let Ik erwd electrician.
Subcontractors: tatthe company name orOtyofFtCollmslicense #
dectridan Plumber Med{ankal Roofer - other
I hereby acknowledge that I have read this application and state that the above infbmiatbon is complete and correct I agree to
comply with all requirements con herein and city ordmanoes and state laws regulating building conshuclion. I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Name_ c ,«. SignatureDateif ;fit i