HomeMy WebLinkAbout821 Province Rd - Applications/Air Conditioner - 04/12/2013From:Poudre Valley Air 9704932073 1 04/10/2013 13:13 #150 P.002/003
City, of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins 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). I1,& Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter 12 Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line. ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater 0 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 #_ I�J� I�� Date t4,;0�\3 2
For oltice use only
Sob Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name . Address
City/State Zip
Phone
- Aa
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
a
Phone
Contractor City of Ft Collins Sales Tax #
sales t9xnumber isrequiredbyall conmactar.
Are you paying taxes here or by report? ❑ Here
Are you paying with your trust account? KYes
50 Report
p No
Is this a residential or commercial project? ETResidential ❑ Commercial
If residential, Is it: Ingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
Multifamily (apartment) ❑ Garage
If commercial, Is it: ❑ Bank ❑ Bar ❑ Church 13 Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or morel ❑ Yes ❑ No If yes, you may need to contact Historic preservation
If this is for a demolition permit, what year was the building constructed?
Ifpr/or to 1975, you W11.1reed an asbestrxs assessment to submit w/th this application.
Description of work
*If lawn sprinkler/backtlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Uy of Ft Co1Uns license g
FJechidan VhC \SA[i��C15 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: t�-
Print Name: ` `�C.D\_ G� W% Signature, Lj� Date _ �