HomeMy WebLinkAbout1912 Dorset Dr - Applications/Electrical - 05/31/2012Fort 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 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 V
manufacturer). (5�
Complete all applicable information on the application. Incomplete applications will not be accepted. G6 i I
Application # b lA s I a4 Date
For office use only
Job Site Address (required) 1'5� I -�-. DC_25 C� —7 1b k Value of Construction (labor, materials, profit)
ereT GB('i'+NS ,60 M7S` $ brSO �
Property Owner Name
Address
City/State
Zip
Phone
1,Afe Y 10er40 tV 17&(4 .
Applicant Name
F0
_ City/State
Zip
Phone
It'���`ICG 7"i 25E
. L0>6
27064`3
L&�tIinIs e C
90Sa-7
ZTZ-i7S7
Contractor Lic #
ddre
City/State
Zip
Phone
WCST��2a,f Shy
o_ o>o
;)_-7064-3 F:j ep �
dl7a '
Z0 805277
282 i7T 7.
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 commercial project? residential ❑ Commercial
If residential, is it: �ff 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 SO years of age or more? ❑ Yes :EkVo 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.
De$cription o work (o<
nk, A71-nP _ U an ray I �-eA t M k 4 1 S-19
*If l6kn sprinkler/bacM8w preventef, 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: ��e� r�E Signature
Date 2.