HomeMy WebLinkAbout2555 S Shields St - Applications/Mechanical - 06/19/2013City of
Fort Collins
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 apRly for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural)4 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 # 22\'�)0?0 4
For ofce use only
Date ulo/ I ?
Job Site Address (required)
`
Value of Construction (labor) materials, profit)
Al 1
5, W_2a. rC m-a
05,itrim
Property Owner Name Address
City/State Zip
Phone
Ap licant Name Address
City/State Zip
Phone
ArInN r,
'
Contractor Address
City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?,J3r Here ❑ Report
sa/estaxnumber is required by all contractors.
35so-� j
Are you paying with your trust account?
❑ Yes <VNo
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑r�,�Church ❑ Hotel/Motel ❑ Medic I off e ❑ Office ❑ Retail
❑ Restaurant 4'J'Other(explain)��0 1, ��An
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-time A/C, must list licensed eI ctrician.
Subcontractors: List the company name or City of Ft Collins /irense #
6-20-13
Electridan fn r'7s � 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: ��)) !
Print Name: ii' kk'n z'_ Signature Date Y' 1�J