HomeMy WebLinkAbout2524 Mathews St - Applications/Reroof - 09/24/2012City Of Planning, Development & Transportation
Fort Collins Fort N. College Ave P.O. Box 580
Collins, CO 4
Phone 970-41616-27402740 Fax 224-6134
OVER-THE-COUNTER 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) ❑ 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 applica information on the application. Incomplete applications will not be accepted.
Application # • V1 � QS-In Date
For offlce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
Spa l/lile r�S $
Property Owner Name
Address City/State
Zip
Phone
Ccv_,'r-t(,s 612
ri 33
r`/I - 23i -
Applicant Name
Address City/State
Zip
Phone
Contractor Lic #
Address City/State
Zip
Phone
nn �rp871
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Contractor City of R. Collins Sales Tax
# Are you paying taxes here or by report?
❑ Here ❑ Report
Sales tax number is required by all contractors.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: ,WSingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If pnor to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backffow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician 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: ((' Q
Print Name: �141-e W)tVR Px4 Signature Date
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