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HomeMy WebLinkAbout2000 Derby Ct - Applications/Mechanical - 05/20/2013City of dart CoWns Planning, Development & Transportation 281 N, College Ave P.R. 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 ❑ 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 # J/ �Od-� �_ _ Date % Q s For oAxr use only Job Site Address, (required) Value of Construction (labor, materials, profit) tom oe?zwsy Gr. -� cD Property Owner Name Address city/state Zip, Phone tay 2M0 T)egay ko Applicant Name Address city/State Zip Phone o - Y Contractor Address City/State Zip Phone C 7� e. � o o.� a• y Y• S5� Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑Report SalesW number dsrequGedbya#cvnnacmm Are you paying with your trust account? ❑ Yes ❑ No Is this a residential or�co�ercial project? LR"Residential ❑ Commercial If residential, is It: M Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex ❑ Multifamily (apartment) ❑ Garage If commerclal, is It: ❑ Bank ❑ ear 0 Church ❑ Hotel/Motel © Medical office ❑ Office ❑ Retail ❑ Restaurant ❑ other(explain Is this building 50.years of age or more? ❑ Yes o lfyes, you mayneeom cnntactHisrontPreseruation If this is for a demolition permit, what year was the building constructed? Tf prior to 1975, you will nwd an asbestos assessment to submft with this appllcad'on. Description of work *If lawn sprinkler/backflow, preventer, must list licensed plumber. If first-tlme A/c, must list licensed electrician. Subcontractors: List the company name or City of Pit Collins license Ar Electrician Plumber Mechanicall H' IbGl 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 thait a permit Is not valid until it has been paid and issued. Applicant; Print rin� ! /_J � PrirrtName:_ 1 (till � / 2F1'L-L Signature Date