HomeMy WebLinkAbout520 Sedgwick Dr - Applications/Water Heater - 09/12/201209/14/2012 10:23 FAX
City of���
Fort Collins
[a002
Planning, Development & Transportation
281 N. College Ave P.Q. Box 580
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). C] Air Conditioning
❑ Demolition (Interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit wn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation 2Water 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 # C9 Date -_- 9- /V-Q 16;L� a�
For office use only
Job Site Address (required)
ged
Value of Construction (labor, materials, profit)
15
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Property Ow r Name Address
City/State Zip
Phone gZt)�
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Applicant Name Address
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City/State Zip Phone
Ff" Lrbl�lYla S>~riZtl knit•-qqN, 1177Ai-
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Contractor L I c.-' I , M P - 91 Address
Nor_*lern h4praci t 7 -S. 6Frltgl 4JA3--1y2
City/State Zip
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Phone
(--r8 -74
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here
❑ Report
sales tax number is requ/red by ad wntradnrs Are you paying with your trust account? 0 Yes
�(No
Is this a residential or_cpmjmfdaI project? IN Resklentlal ❑ Commercial
If residential, Is It: UKIngle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) C7 Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church Cp Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building So years of aye or more? O Yes ❑ No If y&4 you may need to contact HIsloiic Pryrsermtlon
If this is for a demolition permit, what year was the building constructed?
if prkr to 1975, you wl/l need an asbestos assessment to subm/t with this appl/cat/on.
Description of work
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List Me company name or C/ly of Pt COAMS Ileerrwe 0
Secirldan 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 Ilssued. �-►
Applicant -
Print Name: Iti - f .C'I 1 f" IC l L5E'/ 1 signature Date ��