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City of Fort CollinS BUILDING INSPECTION DIVISION
APPLICATION FOR BUILDING PERMIT AND CERTIFICATE OF OCCUPANCY
Applicant complete this part of form only.
Press firmly using ball point pen.
Job Address Zo> " CAa
Name .,tt,�.
Cd'.
Mail Address ;-
3 r.
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Phone _7 r'
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Name
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Address
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License No. ('tx'}
Phonezo
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Lot-_,
Block
Filing Number
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Subdivision -
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PUD
DESCRIPTION OF WORK
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
_ 1
T,otal'SFees
signed' date
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Distribution: Original —Applicant; tslue -Off ce Canary -Sales Tax;'P,`nkµ Applicant; Tat- Insp.
Off -Street Parking
(No. Cars)
Interior Lot
❑
Corner Lot
❑
Reversed Corner Lot
❑
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ZBA Case #
Date
BBA Case # _
Date
Building Insp. f rM\ Approval
by ,,,.r,�s.i date
p'z7
t Permit No.. `
Date