HomeMy WebLinkAbout230 N Loomis Ave - Applications/Electrical - 10/07/2019of 281Planning, Development & Transportation
Fort Collins For 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 ConditioningA Electrical Alteration ❑ Gas Lighter ElGas Log ❑ Heating Unit ❑ Lawn Sprinkler
❑ Mobile Home replacement ❑ Sewer Line ❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove
(must be EPA certified, provide make, model and manufacturer). C2L°`t
Complete all applicabble�infor itiion N
n thhee'application.
PPA lication # ) ✓ 7 � )
For olfice use only
Incomplete applications will not be accepted.
Date 10 1-7 1 \ c�
Job Site Address (required)
Value of Construction (labor, materials, profiit)18oV•°'0
a30 Q- Loomis
Property Owner Name
Address City/State Zip
Phone
ke-• i Wa NnQ r
23o 4�i. Lod*hiS rL Co 530SIA
-M3112-sei 11 -
Applicant Name
Address City/State Zip
Phone
I
C' . 0.,�.�
2-2 2.0 �rc.n FlYl RJR �C-co 205Z�t
p
7c,-SV-H05-7
Contractor
Address City/State Zip
Phone
L6LV0,io ElecFric
Sow as a
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 32�No
Is this a residential or c mmercial project? Residential ❑ Commercial
If residential, is it: 1SSingle 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 mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work SC-rUL c,e- WAln i50 avnV rno fr. ,man CDw � �
4-1. <ann HA
*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: 1,4 La'L Signature
Date I' I `1 It