HomeMy WebLinkAbout3555 STANFORD RD - APPLICATIONS - 12/13/2011Dec. 9. 2011 2:26PM
Encore Electric, Inc,
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City of)1
ort Collins io
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OVER-THE-COUNTER
No.4245 P. 1
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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) fkElectrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement O 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 offlee use only
Date
Job Slt/e/ Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State ZIP
Phone
Applicant Name Address
City/State ZIP
Phone
Contractor Address
City/State Zip
Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? 25 Here
❑ Report
Sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes
❑ No
HO.s"o1
Is this a residential or commercial project? ❑ Residential RCommerdal
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) Q Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, Is It; ❑ Bank CI Bar ❑ Church ❑ Hotel/Motel ❑ Medical office -S Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years off age or more? ❑ Yes R No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprlor to 1975, you will need an asbestos assessment to subm/t with this application.
Description of work
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrlclan. ` _/
Subcontractors: Llst the company name or Qyof Ft Collins license 9 1 2 —I 3
Electrldan/16- "oZ 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::5f4 SP��f I r( Signature Date �� ��