HomeMy WebLinkAbout2803 Des Moines Dr - Applications/Furnace - 04/03/2013APR703-2013 15:12 Prom:Rllen Service 970 4e4 444e To:92246134 Paee:6�14
City of
Fort Collins
Planning, Development & Transportation
281 N. CoAege'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 (oheck all that apply). ❑ Air Gondltioning
D demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
eating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing O Sewer Line ❑ Photo -voltaic
C] Ventilation ❑ Nater 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 # 13 (30i �"5 8
Par orfrce use only
Job Site Address freouir
qua 3 Des .Moines D12
PrODerty Owner Namq^ Address
SjqtibQA- S
,A,plicant Name ,fAddress
)t 6�iri! 0 ��' kCi-1 6'C.- 1 �p ..D • 4! �1�.
Date q-3-/3
Value of Construction (labor, materials, profit)
C G d 8o5a5 Ziwh QO
City state 210
aria
Zip
PhonA
q7 K-755'
Phone
Contractor Address City/state Zip Phone
hod 50 ao5,gq qgq- qgq,
Contractor City of Ft. Collins 5dles Tax # Are you paying taxes here or by report? O Here ,Report
Shcel tax number is regwrV byy an cwt*erors. Are you paying with your trust account? (Yes ❑ No
Is this a residential or Spmmerdal project? {vM.dendal ❑ Commercial
If residential, is 1 Single Family Detached 1*zondoAownhome (single family attached) ❑ Duplex
L1 Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church Cl Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant Q Other (ex laln)
Is this building So years of age or more? Q Yes Vo If yeS, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the Ilding constructed?
If prior to 1975 you will ne&tl an asbestos assessment Co submit with t�io appBcadon,
Deserioribn of
., .0ry11 ,NrmKieyoackrtow prevereter, must list licensed plumber. If first-time A/C, must list licensed electrician.
Sub con tractors' List the company name or City of R CoNins licerrse A'
Electritwn 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 taws regulating building construction. 1 know that a
permit is not valid until it has been paid and issued.
Applicant:Q�t^�l �1n
Print Name
Signatu"Ji—
r Date �...�..._