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City of Fort CollinS BUILDING INSPECTION DIVISION I+l
APPLICATION FOR BUILDING PERMIT AND CERTIFICATi OF OCCUPANCY
Applicant complete this part of form only.
Press firmly using ball point pen.
Job Address ^ter o47
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Name %JPtQLr+l
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Mail Address` �7 ?j <
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Phone �7
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Name p ,1, ( 7nv1 {7
Address �r
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License No. C � � `
Phone
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Lot
Block
IFiling Number
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Subdivision (
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PUD .J
Parcel # C?
DESCRIPTION OF WORK
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Stock Options
Plan No. Codes
Est. Total Cost
(including labor, material, profit)
I hereby acknowledge that I have read this application and
state that the above is correct and agree to comply with all city
ordinances and state laws regulating building construction.
sig-ned i '— �. ( � .date-1 k
f — CLASS OF WORK —
New Alteration Addition Demolish Move
❑ ❑r ❑ ❑
PlAa"i Mae : Elec. / Str, c Fire Prot,
OccaGr.
Type Const.
Use Zone
ruse of Building SPA' Vic
;floorArea g r
Height
N�Storiet(Area
(0150
Frontage S (J
D.
Change from
Plat File No.
No. D.U.
Garage area
Fin. Bsmt. area
Type heat 4=79
No. Fireplaces or stoves
— RELEASES — Dates
Zoning ri) C jcilV3 -
Engineering
Fire Department
Electric Department
Water & Sewer
Plan Review 4 !
Special Conditions: IF
Valuation • "ofFEES_
Plan Check -::2-i
Permit
�1
Parkland
City Sales Tax Q
_
St. Oversizing
OCJi
Water Plant Investment
\ -
Sewer Plant Investment
t
Storm Drainage
Electric Underground
Total Fees-- \
Off -Street Parking
(No. Cars)
Interior Lot rg�
Corner Lot ❑
Reversed Corner Lot ❑
67r m
Y
`m
d
, VV
d _ m
m a m
o,
rflTI 1-•tt 7
ClaCft � �
M-.'0 $
Street AUR. 9 "RJ7.
PRMTS 20
°KFEE 625. Q
c STOVR 575.00
TDTL 1472.70 -
N92746 10:37 A
SEP.12'86
ZBA Case # . Date
BBACase# t Date
Building, Insp. (�, �n7'�dApproval
by
`� 1�X/'
"-Permit No-; .
Date
Distribution'. Original - Applicant, Blue - OlticCaAry '$ales Tax; PinkApplicant,Tag - Bldg. I nsp:y