HomeMy WebLinkAbout743 Boltz Dr - Applications/Electrical - 07/07/2016city ..,f
F6rt Codms
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. Incomplete applications will not be accepted.
Application # Date
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
7L 3 RsM-L--
360, oo
Property Owner Name Address
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City/State Zip
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Phone
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Applicant Name Address
City/State Zip
Phone
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Contractor Address
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City/State Zip
L o .,re lie CD
Phone
Contractor Ci of Ft. Collins Sales Tax #
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? 9� Residential ❑ Commercial
If residential, is it: R 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 5o 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 fNJ44 i1 t,H, &K eD1JX, - Zer_ C?rcLfi CoIA0')fl f_0 6C- 1J 5_6.k"e .
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Listthe 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. A n 1
Applicant: ,p ) �//�� ((�� IIw- 6JAPrint Name: /VGITd'tit� iI.oY Signature
Date 7J )_d