HomeMy WebLinkAbout701 Bentley Pl - Applications/Water Heater - 05/16/2013Ford Collins
of
Planning, Development & Transportation
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). ❑ 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 -ff Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application # P1 3V par94 i v—
For office use an/y.�_��
Incomplete applications will not be accepted.
Date => - 1 0 i
lob Site Address (reg5urired)
Value of Construction (labor, materials, profit)
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Property Owner Name Address
City/State Zip Phone ci7o
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Applicant Name Address
Gty/State Zip Phone
Contractor ,, /h-� Address
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City/State Zip Phone q-?o
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Contractor City of Ft. Colli les Tax #
Are you paying taxes here or by report? s:Were ❑ Report
salestax numaerisreyLffredbya#mnbadors.
Are you paying with your trust account? ❑ Yes Q No
Is this a residential or commercial project? residential ❑ Commercial
If residential, is it: mingle 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 Ifyes, 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 appltcat/on.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty ofr7Colllnslicense
Bectrician PlumlbeiD2L3.,D
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: Q L(JC _ \ Signature 1 \ I Date
Print Name:_ Ctl`L v 1 l d� f
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