HomeMy WebLinkAbout400 Briarwood Rd - Applications/Furnace - 03/14/2013Mar. 14. 2013 11: 33AM
No, 6329 P. 1
City of
F6rt Col[ins
Planningr Development & Transportation
281 N. College Ave P,O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER -THE -COULTER PERMITS ONLY
This application Is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ molition (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 # D-w 2✓- I n
ror of &c use only
Date '04 1 3
Job Site Address (required)
Value of Constt ction (labor, materials, profit)
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Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
Clty/State ZIP
Phone
Contractor Address
Clty/State Zip
Phone
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Contractor City o t. Collins Sales Tax #
Are you paying taxes here or by report?
q Here ❑ Report
Sales t"numberIsregdedbyall rontratYUjs
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or�Com ercial project? residential ❑ Commercial
If residential, is R: t2lingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, Is It: ❑ Bank Q Bar ❑ Church C] Hotel/Motel ❑ Medical office O office ❑ Retail
❑ Restaurant ❑ other (explain)
Is this building SO years of age or more? ❑ Yes Q No If yes, you may need to contact t1lsf0Nc Preservation
If this Is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you will need an asbestos assessment to subrn/t wlb9 this applicatlon.
Description of work
*If lawn sprinkler/backflow preveoter, must list licensed plumber, If first-time A/C, must list licensed electrician.
Subcontractors: Llst the company name or Cy y of Ft Collins &L-nse g
Mectridan Plumber Me6anical_LT_8_ 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: rYa Signature Date ?>/ILI