HomeMy WebLinkAbout2900 Skimmerhorn St - Applications/Water Heater - 08/12/2011Cit o� Planning, Development A Transportation
281 N. College Ave P.O. Box 580
FOrt ^Olt'ns
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
O Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
O Heating Unit IJ Lawn Sprinkler ❑ Mobile Home replacement O 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 # 5 1110 Y6 & Date la\\I
For o e use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Tip
Phone
a
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here
® Report
Sarestax number IsrequrredbyalfcmWadnrs
Are you paying with your trust account? KYes
t3No
Is this a residential or commercial project? %Xitesidential O Commercial
If residential, is it: V Single Family Detached O Condo/townhome (single family attached) ❑ Duplex
Multifamily (apartment) ❑ Garage
If commercial, Is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
O Restaurant ❑ Other (explain)
Is this building 50 years of age or more? O Yes O No If yes, you may need to contact Hcstoric Preservation
If this Is fora demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with bbls application.
Description of work�Ro ahe. t,,nAe.r )kenAe.-
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Qy offT Collins /icenw 0
FJedyidan Plumber Mechanical Roofer
Other
1 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: ` `�l_D� �r_ Signature x�.% Q, — Date g l� Nil
1,00/L00'd BLO# £Z:60 IIOZ/Zi/BO ELOZ£6bOL6 aid AoITPA aApn0d:w0JA