HomeMy WebLinkAbout520 Ponderosa Dr - Applications/Water Heater - 09/24/2012NOV-29-2012 16:23 From:Rllen Service 970 484 4448 To:92246134 Paee:6�6
Planning, Development &. Transportation
City of 281 N. College Ave P.Q. Box 580
For �Qtf i nS 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). O Air Conditioning
❑ Demolition (interior non-structural) 0 Electrical Alteration (not service change) O Gas Lighter ❑ Gas Log
❑ Healing Unit I O Lawn Sprinkler O Mobile Home replacement ❑ Roofing 0 Sewer Line. O Photovoltaic
❑ Ventilation Nate r Heater ( Water Line 0 Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer)) I 11 _ 30
Complete all applicable information on the application. Incomplete applications will not be accepted.
01
For ofCe use
Application ;
Job Site AM
Sao
_�P oDe.rty Ownf
�. rQ.h
Applicant Nam
'Sh(It tI nt
Contractor
13F Date
o� • 00
/reouinerll
IMP Addrm
IP 4A Ry 51
Address
Contractor Citylor Ft. Collins
Sates tar number it tegwred by all
- 1� 4 r l cll� I.
value of Construction (labor, materials, profit)
XD5al ,6
city/State Zlo Phone
515-421A-
Citylstate Zip
6011A w co 905 '7 4
Address, ,� , • City/State Zip
To C5
Tax # Are you paying taxes here or by report? 0 Here
tors. Are you paying with your trust account? 9 Yes
Phone
F A 4.
Phone
Isy-
93_
941
X Report
❑ No
Is this a residential
or 0 mercial
project? esldential 0 Commercial
If residential, I5
it: ingle Family
Detac ❑ Condo/townhome (single family attached) O Duplex
r!!0 Multifamily
(apartment) ❑ Garage
If commercial, i
it: 0 Bank ❑I
Bar 0 Church 0 Hotel/Motel 0 Medical office • 0 office 0 Retail
❑.Restaura
t ❑ Other (extlal }
Is this building
50 years of age
br more? ❑ Yes wo 1f yes, you may need to contact Hlstnrrt Preservation
If this is for a demolition
permit,
what year was the ilding constructed?
If prior to 197S,
you will need an
sbestos assessment to submit with this applicabbn.
-
r
Description or or work _
'+tat-U1�I
*if lawn sprinkle:I/backfiov
Subcontractor: List the
r, must list licensed plumber. If first-time A/C, must list licensed electrician.
name or City of R Collins license 0
Mechanical Roofer
Other
I hereby acknow
edge that I have r
ad this application and state that the above Information is complete and correct. I agree to
comply with all requirements
permit is not valid
Applicant:
Print Name:
contained
until it has been
��rrl�l
herein and city ordinances and state laws regulating building constrUdion. I know that a
paid and Issued.
nzA r� LI 1 �
Signatur _R, Data -