HomeMy WebLinkAbout2612 Belgian Ct - Applications/Electrical - 03/13/2017City of Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
a CD
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 twill not be accepted.
Application # 13 / q0 a `2�� Date � 1 I 13 � ^1
For office use only /00 V v
7o Site Address (required) Value of Construction (labor, materials, profit)
rir✓ 20g-105►-R
2 -1r,s-
Property Owner Name Address City/State Zip Phone
Applicant Name Address City/State Zip Phone
e,�
Contractor Address City/State Zip Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number &mqulredbyall conbaciws Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: P!PSingle 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-VNo 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
*If lawn sprinkler/baddlow 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: /J
�i1 t n 5� f
Print Name: c [ Signature / Date /
Revision date 2/612017