HomeMy WebLinkAbout343 N Shields St - Applications/Electrical - 05/09/2012City Of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
�`} Collins Fort Collins, CO 80524 -�
Phone 970-416-2740 Fax 224-6134 JS
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to appl 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 i ormation on the application. Incomplete applications will not be accepted.
Application # v�—d ;?- Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner Name
Address
Skie S
City/State
69 �oll s co
Zip Phone
645, � `>�� 232 S9(
App�licant Name
(
Address
City/State
Zip
Phone
Contractor Lic #
Address
City/State
Zip
Phone
D3
X (fc-)
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Contractor City of Ft. Collins Sales Tax # Y�� I Are you paying taxes here or by report?
sales tax number is required by ailcontractom Are you paying with your trust account?
kHere ❑ Report
❑ Yes ❑ No
Is this a residential or commercial project? PLResidential ❑ Commercial
If residential, is it: DiSingle 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 X 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.
Description of work n L' 'f
*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: JOu%e�Ol 10.(cC Signatur Date l^�O��