HomeMy WebLinkAbout1706 Rushwood Ct - Applications/Water and or Sewer - 11/08/201211/08/2012 16:48 FAX
Q001
city of
r,Fort Collins
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 for the following permits only (check all that apply). 0 Air Conditioning
0 Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler,01Mobile Home replacement ❑ Roofing Cl Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater 12'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.
Date
Application #
Job Site AC
)7o &
J3laatnl U
For ofl% use only
(mmuimd)
Owner Name
-69
Address
9 �o � yi�ccahw�
Applicant Name Address
rs'bn I `e1Jrt4C:l'1i;e11 ` L(q ., .LeOrk
Contractor L I c.' M P - '5 19 Address
Ncrr1Er1 hipf�uke --� - L
Er4
rn., a 'pins1 7 dq.
Contractor City of Ft. Collins Sales Tax #
Sales bx Iwmber Ls nqubed by al! canhuct
Value of Construction (labor, materials, profit)
%,C---'�`7VZ
Zip Phone
s6vo-11-6 a�qy-
City/state Zip Phone
4'A3•40- 9-74—Wg3--3,i-�U
Clty/State Zip Phone
41A3—IW2 F1. eo I llr� , C6 pC,- ;2q
Are you paying taxes here or by report? X Here ❑ Report
Are you paying with your trust account? ❑ Yes )KNo
IS this a residential or coin dal project? M"kesldential t❑ Commercial
If residential, Is it: MOSSIngle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: Ci Bank 0 Bar I-] Church to Hotel/Motes ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explaln)
15 this building So years of age or more? O Yes 340 .1f yes, you may need to contact H/stodc PMSCIVation
If this Is for a demolition permit, what year was the building constructed?
If pdbr to 1975, you will need an asbestos azes_sment to submit with tf?ls applicatlon.
Descdptlon of work
*If Lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: USt the company name or C77ty of R Coll/ns Aceaw 0
eectrld,w. pWmber Mechanical Roofer
other
I hereby acknowledge that I have read this application and state that the above informatim 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 its not valid until It has been paid and Issued.
Print Name trr �fi't 1 F IC. LE'J_L r Signature