HomeMy WebLinkAbout6826 Nimitz Dr - Applications/Gas - Log, Line, Pipe - 07/09/2013 (3)Cityof Planning, Development & Transportation
} , 281 N. College Ave P.O. Box 580
Collins
IS Fort Collins, CO 80524 \ v
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 O
manufacturer).
Complete all appy5"TAA`(�
n n tpplication. Incomplete applications will not be accepted.
Appllcatlon # Date 2
For office use only I T —
Job Site Address (required) Value of Construction (labor, materials, profit)
(yDr.1$1116no,o6
Property Owner Name Address City/State Zip
I P c CD MIA (7503)253-19610
Phone
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Applicant Name Address City/State Zip
Phone
Cnke ID -► Lve 1 co -7
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Contractor Lic #-� oi� Address City/State Zip
Phone
to - Ov s Ju t io I ice'. 31D t 5111^ St vet
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report?' )d Here
❑ Report
Sales tax number is required by all contractors Are you paying with your trust account? ❑ Yes
No
Is this a residential or commercial project? WResidential ❑ Commercial
If residential, is it: ❑ Single Family Detached Xcondo/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 JVNo If yes, you may ed 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 electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician 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:'W)rma
Print Name: Gr Cc�ke Signature Date