HomeMy WebLinkAbout4915 Fossil Blvd - Applications/Electrical - 05/19/2015City of
Frt 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 the application.
Application # &Z ;(0
For office use only
Incomplete applications will not be accepted.
Job Site Address (required) Value of Construction (labor, materials, profit)
�1915 ca5s, I 81VD $ /000.
.Property Owner Name Address
City/State
Zip
Phone
Applicant Name Address
City/State
Zip
Phone,
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205
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Contractor Lic # Address
City/State
Zip
Phone.
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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 M 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 applicatlon.
work
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*If lawn sprinkler/backflow preventer, must list licensed plum er. 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.
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Applicant:
Print Name: k w L ��v tr ° t Signature Date