HomeMy WebLinkAbout2518 W Laurel St - Applications/Electrical - 01/22/2018Cltyof Planning, Development, & Transportation Services
F�ort Collins Community Development & Neighborhood Services
`lam 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.
Application # 5 U O
For office use only
Incomplete applications will not be ccepted
Date ) - `llll]
Job Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Nam Address City/State Zip Phone
Applicant Name Address City/State Zip 9Phone
Co tractor Address City/State Zip Phone
Ti e Co Fz!25-/2 3 -e;:o a
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number is required by a//contractors Are you paying with your trust account? ❑ Yes ❑ No
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Is this a residenbal or�comm rcial prolect7 Residential ❑ Commercial
If residential, is it- O'Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Mulbfamily (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 morel ❑ Yes Q-N6�lfyes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building cwnstructed7
Descfiption of work/ ff r-el-
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*If lawn spnnkler/bacldiow preventer, must list licensed plumber If first-time A/C, must list licensed electrician.
Subcontractors: list tl7e company name or Qty of Ft Collins license #
Electriciao-f YA%!� Plumber Mechanical Roofer Outer
I hereby acknowledge that I have read this applicabon and state that the above informabon is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulabng building construction I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Name l�iYtDk TV7U/d� Signatu Date
Revision date 2/8/2017