HomeMy WebLinkAbout5103 Star Dust Ln - Applications/Gas - Log, Line, Pipe - 05/28/2013City Of Planning; Development & Transportation
�Y 281 N. College Ave P.O. Box 580
Qrt 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 tha�t apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) 9'Gas Lighter EAGas 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 # '9 136asOI Date 5�- Zf- / 3
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
5-o 5 t,%4 D o 0
Property Owner Name Address
City/State Zip
Phone
cd ess d W o3
Avast FL- 0%5-a
70 -3 7� -z
Applicant Name Address
City/State Zip
Phone
o�
✓oll r /d✓c c, P 6
7-R.G-137�
Contractor Lic # Address
ity/State Zip
Phone
till P6/o
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here CRe ort
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes o
Is this a residential or comm�ercial project? 0
If residential, is it: [Single Family Detached
Residential ❑ Commercial
❑ 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 o If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprior 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-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber ✓K Ili 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: r� � s �_ r 3 Print Name: 1 /��L€t� ��Ea� Signature o Date �