HomeMy WebLinkAbout605 Cornell Ave - Applications/Electrical - 10/21/2015City O� Planning, Development& Transportation
®r ¢6 Collins 281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-41616-2740 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) KElectrical 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 #
For office use only
Date f0,L-)
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address City/State Zip Phone
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Applicant Name
Address City/State Zip Phone
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Contractor
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Address City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? KHere `k Report
Sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes ❑ No
00130i0(D
Is this a residential or commercial project? gResidential ❑ Commercial
If residential, is it: 14 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 I! 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 JMW, -i!. e•i¢( r1 Cci SC'✓u f_r G��Fn� 4lP.i J CIP_4r.4- 1 I hPrP iS
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*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 ME- 1736 �k- 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: _ p
Print Name:
Date