HomeMy WebLinkAbout1809 Crestmore Pl - Applications/Furnace - 10/31/201210/29/2012 14:33 9704844373 BALANCE POINT PAGE 01
planning, Development & Transportation
City of 281 N. College Ave P.O. Box 580
F6r t 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.
3
0`v LP5l5 Date
VP Ic l
Far office use only
o/Qc
--Value of Construction (laff,*rnaterials, profit)
Job Site Address (required)
Property Name Address
City/State Zip
Phone
/Owner
/v c1 4_/�� l°K.rFinar
/ - ld .
r' S' 2 '�YZ
_z G/
Applicant Name Address
City/State Zip
9')0°
c ti J—
Contractor Address
City/State Zip
ii, C� on mere
Phone
ur� C-'l"ni' � ;1...1 lT:
Contractor City of Ft. Collins Sales Tax #
Are y°u paying taxes here or by report? ❑Hereteport
Are you paying with your trust account? /oYes ❑ No
Salr 5 ta.c number is requlitad by all contractors
Is this a residential or commercial project? J�LResldentlal ❑ Commercial
If residential, Is it: &7-9ngle Family Detached ❑ Condo/townhome (single family attached) O Duplex
❑ Multifamily (apartment) ❑ Garage
If cnmmerr_lal, is it: [I Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑Medical office [I office ❑Retail
❑ Restaurant 0 Other (explain)
Is this building so 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? -
Irprior try I s75; you will need an asbestos assessment to submit with th/s application.
Description of work
*If 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 #
Plumber Mechanical Roofer other
I hereby acknowledge that I have read this application and state that the above information Is complete and correctI agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
L
rmit is not> alid until it has been pa-rd and issued.
pticariC: �M�`�r'� /i�',`�nt Name: \ ` �(l, C0^ Signature - � pate \ U t o�