HomeMy WebLinkAbout2924 Cortez St - Applications/Gas - Log, Line, Pipe - 03/22/2013City Of Planning, Development & Transportation
For N. College Ave P.O. Box 580
Fort Collins
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 # 31 ;D 127 3 Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
292 Co. z 5 $ a
Property Owner Name Address
City/State
Zip
Phone
Z4Z J Co,,%1-46z
-Sr. A7%
66s2-S
97o-227-2a1
Applicant Name Address
City/State
Zip
Phone
Contractor Lic # Address
City/State
Zip
Phone
i r>LICA 7-w-lbwls 11F Z5 S6,0O 1
rOtrWTd CT•
8c__5 2L
970 = 2Z5-2V2
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or
by report?
❑ Here 1!�Report
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: )R 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 SO years of age or more? ❑ Yes J IkNo 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 /n/sr-Au, mot; Ntrf 6*-s zi—t 'ra 6Ae-icaP
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician 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:
Print Name: �ikr7ZicL[ i/�u�13i 1G Signature
Date
3
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