HomeMy WebLinkAbout2919 Southmoor Dr - Applications/Electrical - 06/15/2018City of
Fort Collins
Planning, Development & Transportation
281 N College Ave P O Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apfor 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 appZolcleuse
e f mation on the application Incomplete applications will not be accepted
Application # Date I
Foonly
Job Site Address (required)
Value of Construction (labor, materials, profit)
oMvW oo DIZ-
C- BOSZs / 25
Property Owner Name Address
City/State Zip
Phone ��� -9�S
C.oi ro S QS � 0 (' < 2919
S o� ti o r E c C o h in CO 1605
Applicant Name Address
City/State Zip
Phone
sol N M P
(L Pryi7_-rc6,Lis 90711
70— -
Contractor Address
City/State Zip
Phone
Contractor City of Ft Collins Sales Tax #
Are you paying taxes here or by report?
r Here ❑ Report
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes /1"No
Is this a residential or commercial project? Wesidential ❑ Commercial
If residential, is it Igsingle 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 So years of age or more? ❑ Yes No If yes, you may need to contact Heston Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application
Description,of work
*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
501
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 `1 / N U l I *�J� g � � S 2� U
Print Name 1J�\ i nature Date