HomeMy WebLinkAbout5846 Mercury Dr - Applications/Electrical - 02/07/2017City of Planning, Development & Transportation
For281 N. ge ` Collins Fort Collinns' COAve 80524 P.O. Box 580
�- Phone 970-416-2740 Fax 224-61M
OVER-THE-COUNTER PERMITS ONL
Y l�
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conddioning
❑ 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 # �� d lU�� L,
Far office use only
Date L4-b�l oS • 7 / _7
lob Site Address (required)
Value of Construction (labor, materials, p)
50 46 ft r �.
$ 6t43
Property Owner Name Address
City/State Zip 8 0424 Phone Lq j V
O... bo a s �- rib4
. Q8-M' G.) ZY-3 - t 1
Applicant Name Address
City/State Zip Phone
Contractor Address
City/State Zip Phone 'I 10 "
L� i s�^ v 7�rICx q 113
Contractor Gty of R. Collin Sales Tax '#
Are you paying taxes here or by report? M Here 1:;hReport
sales tar number Isrn(ulmdbyat] wn&actors
Are you paying with your trust account? Cl Yes allo
Is this a residential or commercial project? .0 Residential ❑ Commercial
If residential, is it: 'W Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) QAGarage
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 tf yes, you may need to contact H/storfc Presermfion
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you wi// need an asbestos a-vemment to submit with this application.
Description of
- 11 mwn spnnxiegoaamow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Ust 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 I rJ W ,�.' i 11 I }'i V
Print Name: Signature _ li i I ( Cti.-J� Date 13 /