HomeMy WebLinkAbout3703 Full Moon Dr - Applications/Electrical - 12/12/2016Cily Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
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) P 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 # C J �yu I `T ,J 4
For office use only
Incomplete applications will not be accepted.
Date � a I I a l I �0
Job Site Address (required) Value of Construction (labor, materials, profit)
'70*. Full Mom 6,^ Fo, &dz as 9-oo
Property Owner Name Address City/State Zip Phone
FieWA .. 9 SV.«.e t.y _5o
Applicant Name Address City/State Zip Phone
5uST'�X C,l+Ir-ff s 4., (-} 1-170 r 7 W 4 Ay4M be„,,tr, Gv � 0��q -7) 0 _7o • q V)
Contractor Address City/State Zip Phone
Sofa/ 4:1 1 kt I I� I I
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number isrequired byall contractors . Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? a Residential ❑ Commercial
If residential, is it: i Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
��jj 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 Ul I rwJ.e PkP h wllnj Re w k/e.ke,. lawA S, ze
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C. must list licensed electrician.
Subcontractors: List the company name or Co 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: �5� •^ (+(6t Signature 4 Date - I�1'0 •l + a
Revised 1112312016