HomeMy WebLinkAbout319 Parker St - Applications/Electrical - 03/11/2019City of Planning, Development & Transportation
Fort N. College Ave P.O. Box 580
For
/ `1 CollinsJ Fort Collins, CO 80524
Phone 970-416-2740 Fax 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) ❑ 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 # 15 1 ao i
For office use only
Date �J `/— / /
Sob Site Address (required)
�VV a ue of Conn ruction (labor, materials, profit)
rjD
Pro erty Owner Name /,
X,
Vress
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City/State
Zip Phone
" 7!/
Applicant Name
Address
City State
ip r Phon
Contractor
Address
ity/Sta
Zi Pho e
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number i equiredJjyall contractors.
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? 0 Residential ❑ 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 ONo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? A,�d
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 #
Electricidh/ 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:�r)S Si9naturk� � 4 Date / ✓1 �
22-9-