HomeMy WebLinkAbout1204 E Pitkin St - Applications/Electrical - 06/09/2012F
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 the application. Incomplete applications will not be accepted.
Application # Date
Forofficr' use only
lob Site Address (requfted)
Value of Construction (labor, materials, profit)
Property Owner Name Address
Gty/State Zip
Phone
j
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
/
Contractor Ctty of Ft. Collins Sales Tax #
Are you paying fazes here or by report?
❑ Here ❑ Report
Saes tar mxnbw&re ur edbya#axrtradns
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? )Z Residential ❑ Commecia►
If residential, is it: mangle Family Detached ❑ Condo/townhome (single family attadied) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it ❑ Bank ❑ Bar ❑ Church ❑ Hobel/Motel ❑ Medical office ❑ Office ❑ Retail
. ❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you may need tv contact Historic Preservation
If this is for a demolition permit; what year was the building oonstructed7
Ifprior to 1975, you oil/ need an a�sbesias asseonent ho submit witi► ti>s application.
Description of work
*If lawn sprinlder/badAiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subemrbacibors: List the cumpanyname orctyofftCoians/same#
Electrician Plumber Mechanical Roofer
Other
I hereby acknowledge that I have read this application and stale that the above information is complete and correct I agree to
comply with all reirmgnents conmined herein and city ordinances and stake laws regulating building construction. I know that a
permit is not valid until it has been paid and Issued.
Applicant: a'
1
Print Name ""J"o`�'�� Date < -