HomeMy WebLinkAbout2015 Churchill Ct - Applications/Mechanical - 04/23/2013FCity of Planning, Development & Transportation
61 t Colons 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), q Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) 17 Gas Lighter IJ Gas Log
Q Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo-voltaio
❑ Ventilation 17 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 # 8 F301 O L O Date /-/ IS H- a 3
For 11MCL6 uae poly
Job Site Address (mquirl
Value of Construction (labor, materials, profit)
IQ Property Owner Name Address /
City/state Zip phone
ell c C CO
Applicant Name Address
City/State ZIp phone Contractor Address C ' y :
City/State Zip Phone
Za �
Contractor City of Ft. Collins Sales Tax # 03 4 ' y si 55Z
re
tax nur70e'1sre94ired6yallcnntrsm YOU paying taxes here or by report? 4 Here ❑ Report
Are you paying with your trust account? ❑ Yes 13 No
Is this a residential or cc imenal project? Residential ❑ Commercial
If residential, is it; ed Single Family Detached ❑ Condo/townhome (single family attached)
❑ Multifamily (apartment) ❑ Garage ❑Duplex
If commercial, is it: O Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ ❑ Restaurant ❑ Other (explain]].. Office ❑ Retail
Is this building demolition years of age or more? d Yes WNo If yes, you may need to contact H/stt�ric p
If this is fora 5,You;1permit, what year was the building constructed
Ifprior In 1975 You wi//n reserudf/on
y eed an asbestos assessment to submit with this application.
Description of work
C2.1.11>
*If lawn sprinkler/backfiow presenter, must list licensed plumber. If first -tune
S° ntrac#ors: List the company flame or Cdy of g Collins /rcense 0� ' must list licensed eleC ian.
Elec4idan�(_ ��/ 1 Plumber
Mechanical4H-LabRoofer
�—� Other.
I hereby acknowledge that I have read this application and state that the above lnforma
comply with all requirements contained herein and city ordinances and state laws information Is complete and correct. I agree to
Permit Is not valid until it has been paid and issued. regulating building construction. I know that a
Applicant: l
Print Mama:
Signature�� A� Date