HomeMy WebLinkAbout712 Rochelle Cir - Applications/Water Heater - 03/22/2013us
Fit Cotti s
of
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 # 01 J J"J Date "7> Z2,
For o69ce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner Name Address City/State Zip Phone
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A plicant Nye Address Clty/State Zip Phone
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Same C' SE6 ;-50� 3
tract Address City/State Zip Phone
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47- 35206 L�13,-5a�13
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here ❑ Report
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salestafn ee requiredbyailcontraaors Are you paying with your trust account? R"�5 ❑ No
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Is this a residential or commercial project? �(Residentlal ❑ Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank 13 Bar ❑ Church ❑ Hotel/Motel d Medical office ❑ Office ❑ Retail
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❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes o If yes, you mayneed to contact Historic Preservation
If this is for demolition
a permit, what year was th6 building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application,
Description of work
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed efectrfclan.
Subcontractors: List the company name or city of Ft Collins 11cense g
Sectrician 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: D rLh �({ b ,ryt � n
Print Name: ' I ' "I` i "� Signature 4 a u Date �Z
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