HomeMy WebLinkAbout1116 W Magnolia St - Applications/Water Heater - 10/01/201204211203:30p Habrv?iurnbing
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Piannjngr Development & Transportation
281 N. College Ave p.O. Box Sao.
Fort Collins, CO 80524
Phone 970-416-2740 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). ❑ DemolitionWin(interior non-structural) O Electrical Alteration (not service change) ❑Gas Lighter ❑Gas Log
Heating Unit GJ Lawn Sprinkler . pp y}• 0 Air Condiifoning
❑ Ventilation P O Mobile Home replacement Q Roofing ❑ Sewer Line , ❑ Photo -voltaic
Water Heater ❑Water Line 17 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.
Pq Application #
D Date 1�
For office t[se only
Job Site Address (required
Value of Construction (labor, materials, profit)
PropeA:Owner Name Address
city/State Zip Phone
Applicant Name �
^Uu[ V' I City/State J Zip Phone
Contractor �/i �� 11, ., �i�s q
t Address City/State
ZP Phone
fC00antraa-tOr City of Ft. Collins Tax # >7'1 p_
zs tax number /sr2yry�y a// 15 Are you paying taxes here or by report? 13 Mere i r?; R,
Are you paying with your trust account? 18(Yes 13 N
IS this a residential or c mmrcial epro
If residential, is it: P )� � Residential ❑Commercial
Single Family Detached ❑ Condo/townhome (single family attached) • • p Duplex
ult
y (apartment) 0 Garage
If commercial, is It: 1� Bank a Ol Bar O Church 15 o el/Motel E3 Medical office O Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No Ifye_s, Youmayneed to contact y
If this is for a demolition permit, what year was the building constructed? !�°rk Presenrabon
If prtor to 1975, you w/!l need an asbestos assessment to submit with this a
pprIcablon.
of work
;'If lawn sprinkler/backnow preventer, must list licensed plumber. If first�ime
Subcontractors: List thecompany 0, R/C, must Ifst licensed electrician.
name or ofR Co//irzs license ap
Elecoiclan
.Plumber Mechanical
— Roofer Other
I hereby acknowledge that I have read this application and state drat the above information is complete and correct. I agree to
comply with all requirements contained herein and city ordlnances.and State laws
Permit is not valid until it has been paid and issued. regulatlng building construction. I know that a
APPiicant: ,�,/
Print Na . n. � Y t.
Signature
_li/ - / J. .