HomeMy WebLinkAbout5836 Mercury Dr - Applications/Reroof - 10/01/2012City Of Planning, Development & Transportation
�Y I 281 N. College Ave P.O. Box 580
Ort Collins 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). ❑ 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 applicable information on the application. Incomplete applications will not be accepted.
Application # 12 c-) 50�� Date 10 - ( - J7,
For o/tice use only q 5 &?
Sob Site Address (required) Value of Construction (labor, materials, profit)
$ 337-9
Property Owner Name
Address
City/State . Zip
Phone
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c, r4 6011 (N ,
363-q r3- 33y
Applicant Name
Address .
City/State Zip
Phone
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2 3s f{
h3 C" L&Vt)CVtk eo &"53 7 Y70 3l -3e/
Contractor Lic Aa k1J&
Address
City/State Zip
Phone
1\
Contractor City of Ft. Collins ales Tax #
Are you paying taxes here or by report?
MlHere ❑ Report
Sales tax number isrequlredbyall contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? [5 Residential ❑ Commercial
If residential, is it: 121 Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
If commercial, is it:
❑ Multifamily (apartment) ❑ Garage .
❑ Bank ❑ Bar ❑ Church ❑ Hotel/Mote'
❑ 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 prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
❑ Medical office ❑ Office ❑ Retail
*If lawn sprinkler/backflow 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:l� �I
Print Name: Lf rciCl� YP.1 [ �' �' SignaturerrlIQA Date /U �(- I