HomeMy WebLinkAbout2009 Stover St - Applications/Gas - Log, Line, Pipe - 10/18/2012City Of Planning, Development & Transportation
Fort Collins Fort N. College Ave P.O. Box 580
Collins,
CO 80524
Phone 970-41616-27402740 Fax 224-6134 1D �
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 # Date
For oilce use only
Sob Site Address (required) Value of Construction (labor, materials, profit)
s SW $ t M
Owner Name Address
City/State
Zip
Phone
�Property
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6,0 U .Z
70 3V9177
Applicant Name Address
City/State
Zip
Phone
3o w.
� S7� Ff
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S'7o 35y77�
Contractor Lic # Address
City/State
Zip
Phone
Contractor City of R. Collins Sales Tax #
Are you paying taxes here or by report?
ErHere ❑ 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? a Residential ❑ Commercial
If residential, is it: .A9 Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
A❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes Ik No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prlor to 1975, you wi/l need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backnow 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 Adri+S,70'/0/tip 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
Print Name: S5 ar44'e" Signatu DateA::LZ 7