HomeMy WebLinkAbout1100 Poudre River Dr - Applications/Addition or Alteration - 01/28/2013City of
F`rt 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). ❑ 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 # I��`�� Date
For offlce use only
Job Site Address (required) Value Value of Construction (labor, materials, profit)
1100 A'Cuv� k V- Dlz , `-� if "5 $ J 0 .tstl
Property Owner Name Address City/State Zip Phone
M i k,� )tZn��j l l oo-�-D of �Z,Vx1t, �a,�-j-4.111 5
Applicant Name Address
JQr tVtE� 3z15uAi
City/State Zip
=.-t��t� QcPSZ,
Phone
Contractor Lic # Address
City/State Zip
Phone
JlP sr—C 5 D 149 3�t G
�- �CoU��S $a�z,l
993 _11 +1
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?Here ❑ Report
Sales tax number is required by allconrractom
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? ❑ Residential"'�G7 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 If yes, 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 K- AoavZr
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List he company name or City of Ft Collins license #
Electrician �AmS 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: � J /►�,
Print Name: JAB 1 T ' ` Signatur�'�'% rt'i ' "'^ Date l /29/13