HomeMy WebLinkAbout143 N Bryan Ave - Applications/Electrical - 07/11/2019City of Planning, Development, & Transportation Services
Fort 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) X 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 applic le mfo(rmmaat7on the application.
Application # W A
For o ce use only
Incomplete applications will not be accepted.
Date q — 4 ._ i i
0 (10(
Job Site Address (required) Value of Construction (labor, materials, profit)
pw't i -- s 1lov 143 N P)(�C\q AVC Fork Co1\;YJS o521
Property Owner Name Address City/State Zip Phone
(, AllL "11'I 153 9 yksbo,-c ➢(• LadelctnJ Co 90535
Applicant ame Address City/State Zip Phone
Loico bcc4(lc L-4d I5-3 W f5�o(c D(. Lovdctn6 Cor 8053 g:70-bq(':'-z963
Contractor Address City/State Zip Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report?,,W Here ❑ Report
Sal uTbFrisleguj. dbyall conbacto75 Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? )N Residential ❑ Commercial
If residential, is it: Z 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 O 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 g t P I ckc, n o X 15
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C,. must list licensed electrician.
Subcontractors: List Me company name or City of Ft Collins license#
ElectricianLoyo EICC16C. 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.
A licant: An
Print Name: 3 e? � i rA l r I Clay l�iynature �M U Date
V V
Revision date 2f62017