HomeMy WebLinkAbout637 W Lake St - Applications/Electrical - 06/16/2017City 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) ❑ 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. �g�
Application # RJ k-1 D 3 S- Date 06/16/2017
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
637 W Lake Street $400.00
Property Owner Name Address City/State Zip Phone
Comcast of Colorado 1617 S Acoma Street Denver CO 303-603-5627
Applicant Name Address City/State Zip Phone
Contractor Address City/State Zip Phone
Tri City Electric II Inc. 813 East 18th Street Unit 6 Greeley, CO 80631 970-352-5731
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ® Report
Sales tax number is required by all contractors. Are you paying with your trust account? ❑ Yes ❑ No
24061
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 office ❑ 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 Electrical Hook Up Remote TV Cabinet
*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
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: Beth A Neuerburg Corp Se pure 9&?t 4 /���� Date 06/16/2017
Revision date 2ro/2017