HomeMy WebLinkAbout1200 Matuka Ct - Applications/Electrical - 06/01/2015City of
Flirt C® Ons
Planning,, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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This application is to be used to ap� for the following permits only (check all that apply). El 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.
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Application #11 II L1 n',111
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L�F& office use 04- J
Job Site Address (required)
" 5 76- �" Value of onstructian (labor, materials, profit)�•4
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Property Owner Name
Addres
I'qCity tate Zip
Phone
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Ap licant Name
Address
City/State Zip
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Phone
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Contra or
Address
City/State Zip
Phone
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Contractor City of Ft. Collins Sales Tax
# ` ,$ (6ZpZAre you paying taxes here or by report? ❑ Here ❑ Report
sales tax number is Wedbyalignrractors
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? ivy' Residential ❑ Commercial
If residential, is it: ingle Family Detached ElCondo/townhome (single family attached) El Duplex
VMultifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explai )
Is this building 5o years of age or more? El Yes IYNo Ifyes, you mayneed 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.
of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcon acto"Ih5tcompany 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: I\> 1pr/
Print Name,; -`�h l �� Vt.ctiQ.Q/ Signature ��G �.i Date el ( - �zo