HomeMy WebLinkAbout502 Jansen Dr - Applications/Reroof - 09/02/2011c.tty of 281 N. College Ave P.O. Box 580
�t Collins Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVERmTHE-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 #:011 b(p[q Date
For office use only . AT A
Sob Site Address (required)
Value of Con
uction (labor, materials, profit)
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Property Owner Name
Address
City/State
Zip
Phone
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Applicant/Name
Address
City/State
Zip
Phone
Contractor
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Address
City/State
Zip
Phone
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Contractor City of Ft. Collins es Tax #
Are you paying taxes here or by report? ❑ Report
Sales tax number is required by all contractors.
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Are you paying with your trust account
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Is this a residential or commercial project? A
If residential, is it: Single Family Detached
Residential ❑ Commercial
❑ 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 ANo 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.
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician. y
Subcontractors: List the company name or City of Ft Collins License A
Electndan 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
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Print Name: i f' ✓ r'r �1 (eAd l Signature ��GL Date