HomeMy WebLinkAbout3219 Nesbit Ct - Applications/Gas - Log, Line, Pipe - 11/04/2011CitytOf c %,j (/0 Planning, Development & Transportation
Flirt Collins " � Phone970 4, CO 80524 F281 N. College Ave Oa g224-6g134
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 2f 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.
Application #
For offi4 use only
Incomplete applications will not be accepted.
Date
Job Site Address (required)
Value of Construction (labor, materials, profit)
3zw col^ra-
f% L� 4 Soo--'o
Property Owner Name Address
City/State Zip
Phone
�iak n�re,� V:616en 32K Nesb4 CO A
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20u-1 vo--
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
P0eAM0'n'A Cc"4Tr -?'n 1('Lm cc'j-� $05N
17$- 1r�30
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
szraxmder is required by all contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? P<Residential ❑ 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 ti:rNo 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
*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 #
p
Beddow \Tr" Plumber Co� ,k O Mechanical Ma<11111 Roofer I'A 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: ,, II IIL1,�- � 1 /
Print Name: MZAL- AAK?J� Signatures f7 % Date Z.