HomeMy WebLinkAbout1117 Centennial Rd - Applications/Electrical - 05/09/2019City of Planning, Development, & Transportation Services
Flirt Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 970.416.2740
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 # N a 0?on Date 05/09/2019
For office use only
Sob Site Address (required) Value of Construction (labor, materials, profit)
1117 Centennial Road, Fort Collins 80524 $1,250.00
Property Owner Name Address City/State Zip Phone
Julie Chantry 1117 Centennial Road Fort Collins, CO 80524 970-402-8331
Applicant Name Address City/State Zip Phone
Tanya Charbo 2601 S. Lemay Ave., Unit 7 #431 Fort Collins, CO 80525 970-460-6550
Contractor ME-1435 Address City/State Zip Phone
Winterhawk Electric 2601 S. Lemay Ave., Unit 7 #431 Fort Collins, CO 80525 970-460-6550
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
00131450
Is this a residential or commercial project? lZ 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 la No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work Electrical - replace existing panel with new 200 amp panel.
*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:
Print Name: Tanya Charbo, Winterhawk Electric Signature Date 05/09/2019
Revised 111232016