HomeMy WebLinkAbout3025 Rustic Ct - Applications/Electrical - 06/06/2012 (2)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 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 he application. Incomplete applications will :
not be accepted
Application # bl7 ? X" J Date
For offrce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
30 a s Ru,s ;� C.Is 00
Property Owner Narne
-
Address
boas
City/State Zip
R,9- I � I
Phone
Applicant Name
Address
City/State Zip
Phone
2121 Springfield Drive, Ft Collins, CO 80521
Contractor Lic #
Address
City/State Zip
Phone
Pinnacle Electric ME654
& communications Corp
2121 Springfield Drive, Ft Collins, CO 80521 970-221-4905
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
Sales lax number is required by all contractors
city # 35133
Are you paying with your trust account?
❑ Yes )! No
Is this a residential or commercial project? ❑ 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.
*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: > 0.)
Print Name: Ck3 �^f7
Date O -u ` o Z `