HomeMy WebLinkAbout417 W Magnolia St - Applications/Electrical - 08/23/2018City of Planning, Development, & Transportation Services
Frt Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
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) 'K 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 # td 1,0 W D
For office use only
Date 1�,--17j� , 14
Job Site Address (required) Value of Construction (labor, materials, profit)
q/7 Mk-_,"oLtN sr. FcR-r 905-LI 1stz 000
Property Owner Name Address City/State Zip Phone
Cr-r o u. s .306 I-NW�MrL e..t Cos,w is cc3 8os o z-z.i - 9879
Applicant Name Address City/State Zip Phone
W arm Ptt,, 1401 duF b21ur,_ FORT Lu.Js Cry 906- Z_1Y 97iD 7-2l- 1776
Contractor Address City/State Zip Phone
sT s ( t /gel buFF bR. FJtf LL'" s
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here AReport
Sales tax number is required by all contractom Are you paying with your trust account? ❑ Yes ❑ No
36-2tig
Is this a residential or commercial project? ❑ Residential (21 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 Mother (explain) LioCv e+ Ci,,rrrJCr, - Pr%9FoR.►APf.Wr, gAct
Is this building 50 years of age or more? ❑ YesK No Ifyes, you mayneed to contactH/storicPreservation
If this is for a demolition permit, what year was the building constructed?
Description of work LrZb Aisttc- L,c.,in. i6 ,•j 7%C PkkrZ;,tMA+JcA_ 9Ati
A-r t'i`rL_ C_� ,
*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 MF. - 77 Z 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: II ��[[
Print Name: t/ cat_ gutLl Signature Date 46 3 1 v
Revision date 2/6/2017