HomeMy WebLinkAbout642 Rocky Mountain Way - Applications/Electrical - 06/05/2018City of Planning, Development & Transportation
Fort Collins 281 N College Ave P 0 Box 580
Fort Collins, CO 80524
Phone 970 416 2740 Fax 224 6134
OVER-THE-COUNTER PERMITS ONLY q 5�
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 #y) DO Li Date � ( 5 h $
For office use only
lob Site Address (required)
Value of Construction (labor materials
profit)
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Property Owner Name
Address
City/State Zip
Phone
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Applicant Name
Address
City/State Zip
Phone
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Contractor
Address
City/State Zip
Phone
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Contractor City of Ft Collins Sales Tax #
Are you paying taxes here or by report? IXHere
❑ Report
sales tax number is required byall contractors
Are you paying with your trust account? ❑ Yes
XNo
Is this a residential or commercial project? Wesidential ❑ Commercial
If residential is it ((Single 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 may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If poor to 1975, you will need an asbestos assessment to submit with this application
Description of work P�Q(ffl— toy FPS
*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 bcense #
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 CJ NA+ L,.mb Signature
Date 6` S/ 1-'<;'