HomeMy WebLinkAbout1020 Castlerock Dr - Applications/Electrical - 03/28/20197:7B9S
City 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 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 # {� C7 I 1 Date "a �-
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
/09.0 Cces-�-/ C r
/2 eaq,06
Property Owner Name
Address
City/State Zip
Phone
RObPr11-- Reec /O
C"sf/c oc
Or you-ayai'
Applicant Name
Address
City/State Zip
Phone
Jov\ l� �,9 ol
E COvh
ci 8eP YY 0- gaS/3
Wo-S66-Y/8
Contractor
Address
City/State Zip
Phone
_7A,1 /a7� 74-, `
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rIXou ! gds/J
7v-s66 - yi$r
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? . �9 Residential ❑ Commercial
If residential, is it: 0 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 Ifyes, you mayneed to contact Historic 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 hs/z, // new rvw; � A'rco n e 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 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: r
Print Name: �JO >\ Ta_\110 Signature
Date 3 -J 1F