HomeMy WebLinkAbout2501 Midpoint Dr - Applications/Electrical - 09/01/2015CityOfF
F=�6, rt Co ons
(Planning, Deveicpment &A Vransportatimn
281 N. College Ave P.O. Box. 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
®VCR-W E-C OUMYER PERME4S 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 # r6150 (p5oq Date
For office use only
Job Site Address (required)
7-5 A(J 4
�,/� Vaiue of ConstrucUl on (labor, materials, profit)
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Property Owner Name Address
City/State Zip
Phone
Ap ican Name , d''r^/�Address
✓
Sµ,��City��� � Zip
7 9� 5�
Contr ctor Address
D i C. //� L' /.
City/State Zip
WO r'—dd� g 7
Phone
970 77� 'Ov
ontractor City of Ft. Collins Sales Tax
Sales tax number is required by all contractors.
Are you paying taxes here or by report? 159-Here ❑ Report
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
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical pffice ❑ Office ❑ Retail
❑ Restaurant Bother (explain) .- 9 KoV
Is this building 50 years of age or mode? ❑ Yes ❑ No If yes, 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.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. 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
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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 ar}� state laws regulating building construction. I know that a
permit is not valid until it has been paid and issued. 1 \, f
Applicant:
Print Nam
It 4 Signature
Date
AN