HomeMy WebLinkAbout4616 S SHIELDS ST - APPLICATIONS - 4/3/2013Sep 2712 01:10p South Paw Electric Corp.
720-890-2906 PA
City of Planning, Development & Transportation
281 N. College Ave P,O. Box 580
Fort Collins 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 perinits only (check all that apply). Q 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 #
For ofte use only
Date 3� /%� f 3 + 3
Job Site Address (required)
Value of Construction (labor, materials, profit)
W91(O 3,
shield
•000 W
Property Owner Name
Address
City/state
Zip Phone
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Applicant Name
Address
City/State
Zip Phone
'
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Erie,, CC) 86SIC0 603 tY-
Contractor
Address
City/State
Zip Phone
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?01q 91CaSCtrif
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Contractor City of h. Collins Sales Tax #
Are you paying taxes here or by report? Here ❑ Report
Sales tax number lsrequlredbyall contractors
Are you paying with your trust account? Yes ❑ No
Is this a residential or commercial project? ❑ Residential gCommercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townheme (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant KOther (explayi)�Vldy 1
Is this building 50 years of age or more? ❑ Yes MNc Ifyes, you may need to conntactHlstoric Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you M/l need an asbestos assessment to submit with Ghis application.
I hereby acknowledge that I have read this application and state that the above Information Is complete and correct. 1 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.
Print Applicant:
Name:Ci'lA.il'te-t 11461jet/f/ol � �
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