HomeMy WebLinkAbout4108 Rolling Gate Rd - Applications/Electrical - 11/30/2016c i rPlanning, Development, & Transportation Services
F6et Collins Community Development & Neighborhood Services
F 281 North College Avenue
Fort Collins, CO 80524 970.416.2740
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 # kJ I�U 7 I 0 Date 1 I I t 0
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
4 / 0,3 Ralf C R + C'rJll ia S C0 &7(0 I aD
Property Owner Name Address City/State Zip Phone
l�a-�� �011 e�(n Wal toy Collin q7,!, ?-179
Applicant Name Address City/State Zip Phone
Sha n aao `Po 5_,5K y 3 L.avelco'd L' $053
Contractor Address City/State Zip Phone
Y1 aC IeG Fri C Fa /-/ L v l roc( 5 q7o- i 0y�
Contractor City of Ft. Collins Sales Tax # Are you paying "taxes here or by report? a- ere ❑ Report
Sales tax number isrequired byall contractors. Are you paying with your trust account? ❑ Yes L9 0,
OUa38 `713
Is this a residential or commercial project? Q Residential ❑ Commercial
If residential, is it: RSingle 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 P o 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 I Pl.S+Q 11 N E M F} lg — 50 ou, + b4 —io Oka! e // Sl at
*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: c//�
Print Name Gi(1()0 MtLgL 1.49nature //` Date
Revised I IJ2312016