HomeMy WebLinkAbout1611 S College Ave - Applications/Electrical - 04/24/2017City of Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
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) EFElectrical 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 # 1 I:l )ZJ� heV Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
1 (0 11 .S . Co(L .C, CIS -AJ:7 �30 '3855
Property Owner NWme Address City/State Zip Phone
Toro, IINw sok 5 P F&Qf)(l 20 oao
Applicant Name Address City/State Zip Phone
H-a'Ott Mic-0 Po f�)x 2.�3o97_ r-t, bfU'v6 tL KOG2-7 I7D-918-l95q
Contractor Address City/State Zip Phone
Pam Nkulc/k�a CGYVLLtJbr I{ Po box o27130g1'�- Ft-C 1kg3 W �i)527 y�o e�8 18s9
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here �eport
sales tax number is required by all contractors. Are you paying with your trust account? ❑ Yes No
ool'3Salz J
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 f
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office 0 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?
Description of work 3 Y 1
*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- ICAR 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:
Print Name:' �.�&u., f I - wo Signature Q_ ( ' t1�U LtS?� Date
Revision date 2/612017