HomeMy WebLinkAbout514 11th St - Applications/Gas - Log, Line, Pipe - 09/05/2012SEP.0.�-2012(WEO) 09:08
P. 001 /001
City of Planning, Development & Transportation
F6rt Cabins Fo t Collins, Co 80524 P.O. Bat 580
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This applicatlon is to be used to apply for the foticwing permits only (check all that apply). Air Conditioning
Demolition (interior non-structuraq Electrical Alteration (not service change) Gas Lighter s Lo
Heating Unit Lawn Sprinkler Mobile Hame replacement Roofing Sewer Line Photo -voltaic
Ventilation Water Heater Water Line Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Comoloto all applicable information on the application. Incomplete apolicationswill not be accepted.
Applicatlon # I c
For alike Use only
Date fr 1 �. 1;r oC�
Is this a residential or
If residential, Is It -
Commercial
nhorne (single farnlly atmehed) Duplex
Multifamily apa ent) Garage
Ir commercial, is it-, Bank Bar Church Hotei/motel Medical office office Retall
Restaurant Other (explain)
Is this building 5o years of age or more? Yes No Itym you may need to mnractHistoric Prescrvation
If this is for a demolition permit, what year was the building constructed?
Ypnor tv 1975, ynu will need an asbe!;Yos assess-mcnr to submit w1tl, this application,
ption of work
*If lawn sprinkler/baddlow Preventer, mum list licensed plumber. Ir First-time A/C, must Ilst licensed electrician.
Subcontractors: USt the company name or City of Ft Collins license a
Eimtridan� — Plumber Mechanlml Roorar.
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 bccn paid and Issued.
Applicant 1 1�''�—r�
Print Name:_ Cl ` P n�'.�._ Signatu Deco