HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Applications/Water Heater - 04/16/2013City Of Planning, Development & Transportation
Fort Collins Fort Collins,College Ave P.O. Box 580
Fort CCO 80524
Phone 970-41616-2740740 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 # D 130 (11 9 Date 14 ` 13
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
4-6'�20 �s, r J GG� few $
Property Owner Name
Address City/State � Zip Phone
r /ry co 62-ZE 12T7 9
Applicant Name
le W �AwIL, _2�
Address
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City/S to Zip Phone
- 4c- " -PS�S 3a�Q�PG
Contractor Lic #
k)ps 1"J L 673
Address
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CityState Zip Phone
e 9 ze
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? [Mere ❑ Deport
Sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes No
Is this a residential or commercial project? X 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 ❑ No 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 -tame A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber 6 23 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 r ing building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant:�� ���
Print Name: �/ Signature
Date ?— _/��