HomeMy WebLinkAbout1205 W Elizabeth St - Applications/Plumbing - 06/07/2013Fort 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 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 # 13 / 30 �1� 5a Date 1-7 ► 3
For offlce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
/705- W e_0 Q-V-24�-i 04re A- $ 35 0o. o,-,)
Property Owner Name
Address
City/State
Zip
Phone
fUsl.OI C/t&
Pa
6,60V 72-9
,CC Co
57Z
70-2_a6-/o30
,,Ovs
Applicant Name
Address
City/State
Zip
Phone
_ lL)
tjs
90 ✓ ll
(- Cam'
9)) 2L
970-6L4 271
Contractor
Lic #
Address
City/State
Zip
Phone
ykilo
610
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here 54eport
sales taxnymberisrequiredbyall contractors
�/ 630
Are you paying with your trust account?
❑ Yes O'1l0
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 ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
EKe-staurant ❑ Other (explain)
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.
of work S¢'u a J >f- b✓R SIB i,44 t 4¢� e.G ..J4 1-0
*If lawn sprinkler/backfiow 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 Q 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:) d� 09M&L 3(� Signature � Date