HomeMy WebLinkAbout3748 Ashmount Dr - Applications/Furnace - 08/27/2012Fart Collins
of I
Planning, Development & Transportation
281 N. College Ave P.O. 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 forthe following permits only (check all that apply). C] Air Conditioning
Cl Demolition (interior. non-structural) ❑ Electrical Alteration (not service change) 0 Gas Lighter 0 Gas Log
❑ Heating Unit ❑ Lawn Sprinkler 17 Mobile Home replacement ❑ Roofing El Sewer Line O Photo -voltaic
0 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 # L 1 ;L 14 ` - l
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Date 5a I H3
Job Site Address (raprmre)
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
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Contractor Address
Clty/State Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here AReport
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Are you paying with your trust account? V Yes ❑ No
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Is this a residential or commercial project? Residential 0 Commercial
If residential, is It: Single Family Detach ❑ Condo/townhome (single family attached) ❑ Duplex
Multlfamily (apartment) ❑ Garage
It commercial, is it: 0 Bank 0 Bar 0 Church ❑ Hotel/Motel 0 Medical office E3 Office ❑ Retail
❑ Restaurant 0 Other (explain)
Is this building 50 years of age or more? Dyes ❑ No Tf^ yrrrnnayneed ivcoYJLWH6liirkPmem iW
If this is for a demolition permit, what year was the building constructed?
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Description of work
*If lawn sprinkler/badcflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Lisimeavnyk3nynarneo e0tyafRCati}mNlzse�
Elecbidan INumper MedWlral =00�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:
Print Name, Singe ae Date _!�24 12%