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HomeMy WebLinkAbout217 S Mack St - Applications/Electrical - 05/15/2012p!faitiE� ` Transportation City of 8i �fox 580 Fort Collins i orf. Phone"X 224-6134 " ❑ Air Conditioning This application is to be used to apply.foi the,4446 ylfi perm tie; FYI- ": M ighfer M Gas L ❑ Demolition (interior non-structural) ❑ Electricailtefatl_a (notsei . ; 09 v w. ❑Heating Unit ❑ Lawn Sprinkler ❑ Mobile Holes replan r7lent.'L7 ., ' ne, . ❑ Photo -voltaic ❑ Ventilation ❑ Water:Heater ❑ Water Line ❑`leot!!P� llet Sinu'<( ". , . provide make, model and* manufacturer). ;•:..:'.o,� 'Complete all applicable information on the app[Iaa�on► Inco :. Aot be accepted. ,'. Application # .FOrOfIiCeUSeonly = Job Site Address (required) (1. ", materials, profit) -..ar' ry Phone Property r Name [ w s' 1p P Owner a Address, Cif': is etc n E(r' vnfcv, �7D-69)�7?mp ;-Y,. Applicant Name Address:': a' � � °,,a;,,,;> :'ZiA Phone. Contractor Address.. Cyr/=� ` Z►p Phone Contractor City of Ft.. Collins Sales Tax # Ve yolk report? f] Here- Sa/estaxnuyymderisrequiredbyafrcanrracfors i re yott pa unt? © Yes �]-W, : p ? 'i[t.. Q' C�mlmell,la1�'•$�z�'.. {�'�•ST.'�.�'.' Is this a residential or commercial project? e5lderklal '. Land townhorria{ ed') ❑ Duplex If. residential, ►s it: ngle. Family Detached la . ❑' Multifamily (apartment{, If commerclal, is it:. D Bank ❑ Bar D Church p Hotelt, otel , D ❑ Retail i; ❑ Restaurant ❑ nther'( twin) Is this building 50 years of age or more? j es,;':,:.0' No ! lfyes` yefaT . " .' � � Pi�servation If this is for a demolition. permit, what year w„as:t#+e;b�ildi IMF .: If prior to 1975, you. Mil need an asbesfos assessi�t t 05 mit th. tff "" Description' of work ' r YA (J fl0 xx :r *If lawn sprinkler/backflow preventer, must list licensed: plymi+. If fitst�Ef, electidan. Subcontractors: U'st the company name or Gty of Er Edll;bi ..jkii a :, '`,.:;<: , .:_ { 'i l .at''. Other Electrician Plumber -- 'Metrltcal - r� i —� q. .. _' ` .` a and correct.. I agree to I hereby acknowledge that I have read this appticatldq:and staff that t ': nR! t construction. ow that a: comply with all requirements contained herein and:city;iirdiiian artd� $Ei3f .: ,. permit is not valid until it has been paid and issued., Appill . Print Name: V''` ��iLrP ��s� _ si9n{ltur?p - :date 4 M'yK' Z0 39bd 103-13 SNI-1-103 1603 6PK8990LG 91:6I ZZOZ/EI/90