HomeMy WebLinkAbout721 Remington St - Applications/Electrical - 05/23/2012CityOf Planning, Development & Transportation
Fort Collins Fort N. College Ave P.O. Box 580
Collins, CO80524
Phone 970-416-27402740 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 #y?U "? Da e a3 ao�a
For o>ficeuseonly 2�l� O7
Job Site Address (required)
Value of Constrpction (labor, materials, profit)
l rs C�
05 f� ar `c)
Property Own r Name
Address
City/State Zip
Phone
i6eokw atrar-70?
Z-o?d>-027
Applicant Name
Address
City/State Zip
Phone
ie 90,%5
9x-Pf VQ
3(9
i
Contractor
Address
City/State Zip
Phone
r-- ct �vn
e
Sa a
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here &Report
Sales tax nu� j requkeof 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: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
X 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.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-timd7A/C, must list licensed electrician. /n[llL�/�
Subcontractors: List the company name or City of Ft Collins license # e ^ v
, _ Electrician /"/`:Z) � 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: �On_ S. Signature
Date T— 23
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