HomeMy WebLinkAbout1917 S Shields St - Applications/Furnace - 11/26/2012el
City of Planning, Development & Transportation
y 281 N. College Ave P.O,. Box 580 -
� 6rt CoWns Fort Collins, CO 80524 j
Phone 970-416-2740 Fax 224-6134
NOV 26 2012
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). 0 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 # J3 I.;)-o -7o I Date /�07�'/�
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
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Contractor City d Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here 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? t5(Residential ❑ Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) .❑ Duplex
Multifamily (apartment) ❑ Garage
If,commercial, is it: ❑Bank ❑Bar ❑Church ❑Hotel/Motel ❑Medical office ❑Office ❑Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No Ifyes, 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
*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: / llr�
Print Name; SignatureDate