HomeMy WebLinkAbout1200 E Pitkin St - Applications/Electrical - 06/09/2012Planning, 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-vottaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and.
manufacturer).
Complete all applicable information on the application.
Application * % t 0klz)Q�r�3M
For offs a Lm only
Incomplete application; will not be accepted.
Date 9
lob S'-te Address (squad)
Value of Construction (labor, materials, Profit)
Property Owner Name
Address
City/State Zip
Phone
Applicant Name
Address
City/State Zip
Phone
Contractor
Address
city/state Tip
Phone
/
Contractor city of Ft Collins Sales "fax #
Are you paying taxes tie or by report?
❑ Here ❑ Report
Sales raxmrnbe jvte%*edbyaOmnhaCWM
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? )2r Residential ❑ Commerdat
If residential, is it OSmgle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Muttilamiy (apartment) ❑ Garage
If commercial, is it- ❑ Bank ❑ Bar ❑ Church 0 Hotel/Motel 0 Medic office ❑ Office ❑ Retail
0 Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you may need to contact Nismric Prese wtion
If this is for a demolition pert% what year was the building constructed?
Ifpnor to 1975, pw MY need an asbestos assessment to submit witlr dus applicatiom
Description of work :ytu rr- .._ 1, - Jrr •- ``) %:. , _ .. .. .. ; S
*If lawn sprinlder/baddlow preventer, must list licensed plumber. If first-time A/C, must list licensed elechidan.
Subeonitamors: List the company name or Uy oft Cooties /ica nw #
Elecbidan Plumbs Me<hartical Roofer Other
I hereby admowledge that I have read this application and state that the above information Is complete and correct I agree to
comply with all requirements oontherein and city ordinances and state laws regulating building conshuction. I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Name.: _,- SSgrrature - — Date