HomeMy WebLinkAbout420 Park St - Applications/Mechanical - 09/25/201209/25/2012 TUE 12:17 FAX
Z 001/0071
Gil of Planning, Development & Transportation
0 �I 281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-4116-2740 Faxx224-6134
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
X1 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 applicable information on the application. Incomplete applications will not be accepted.
Application # �O 5 1 Date
For office use only � J L4 _ i2b
lob Site Addr s (required)
D 4,2K S'T,
Value of Construction (labor, materials, profit)
SD
Pro rty Owner N me
bhp uS6269UE
Address /�I'ty/State Zip
,QK �T GG/ C
Phone
Applicant Nam
E� Y EIDG� %
Add ess Ci State Zip
0 �Lin�i
Phone
ontractor
Address ItaleZip
a��rFl�co Co goo 0
Phone
3�3-5�lod �
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? AHere ❑ Report
sales tax number is required by allmnrractors. Are you paying with your trust account? ❑ Yes 21 No
Is this a residential or commercial project? 9 Residential ❑ Commercial
If residential, is it: 95 Single 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 IgNo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?, J1/�&
lfprior to 1975, you will need an asbestos assessment to submit with this application.
Of
lawn sprinkler/backfiow 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:
Print Nam,
Date 1 �-
IV
��O��o ���GG�S� � G��P/L/%�F (✓GG 7"'-_ �u.�--yCo�a -Y al � 7