HomeMy WebLinkAbout760 Eastdale Dr - Applications/Gas - Log, Line, Pipe - 06/28/2013CI Of Planning, Development & Transportation
Cam+},. 281 N. College Ave P.O. Box 580
■jl OI ! :CO11I11S.. Fort Collins, CO 80524
~ t r 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 #yl �J�3o2G/� Date U f.9 I )
For office use only—T -
Job Site Address (required)
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100GT+
Value of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State Zip
Phone l
Vat INICHaa Cox
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Applicant Name
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Address
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City/State Zip
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Phone
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Contractor
Address
City/State Zip
Phone,
Contractor City of Ft. Collins Sales Tax
#
Are you paying taxes here or by report? ❑ Here
❑ Report
Sales tax number is required by allmntradom
Are you paying with your trust account? ❑.Yes
❑ No
Is this a residential or commercial project? O'Residential ❑ Commercial
If residential, is it: L6'Sringle Family Detached ❑ 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 ❑ No If yes, you mayneed 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
*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 #
Electricians � I 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: �f
Print Name:'signature
Date
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