HomeMy WebLinkAbout5901 Southridge Greens Blvd - Applications/Reroof - 09/16/201109/15/2011 22:28 9703539774 INDEPEDENT ROOFING I PAGE 02
City, of
rt Collins
Planningr Development &Transportation
2.81 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
O Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit C] Lawn Sprinkler ❑ Mobile Homo replacement XRoofing ❑ Sewer Line. ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line Q 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 # B //d 1: a C) o2 Date A (o /afl I I
For office use only.
lob Site Address ( ulred) �d , Value of Construction (labor, materials, profit)
5qD► I�VAJdao.'Aj_1at -A f (01 sits. i
Pro rty Owner NaT , Address City/state Zip Phone
Gc) os o2l-'t 57a
Applicant Name Address City/State Zip Phone
Same
Contractor Lic*R294 Address City/State Zip Phone
:Independent hoofing Inc.. 405 22nd St., Greeley, CO 80631 970=353-1389
Contractor City of R. Collins Sales Tax #
Sales taxnumberls req&rad by all contrauors
Are you paying taxes here or by report? O Here ?l Report
Are you paying with your trust account? X) Yes ❑ No
Is this a residential or.cgmmercial project? ® Residential ❑ Commercial
If residential, Is It: 0 Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) 0 Garage
If commercial, is it ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office O Office ❑ Retail
El Restaurant ❑ Other (explai
Is this building 50 years of age or more? ❑ Yes WNo Ifyes, yvu mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building Constructed?
If poor to 1975, you col11 need an asbestos assessment to submit with this applicatio17.
of work
*If lawn sprinkler/backliow, preventer, must list licensed plumber. If first-time A/c, must list licensed electridan.
Subcontractors., L&T the company name or cay of Collins licex,e o
dectiidan Plumber Mechanical Roofer k aCl lit Other
I 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. ordinarims and state laws regulating budding construction. I know that a
permit Is not vaild until it has been paid and issued.
.Applicant: I / -
Print Name: 1 I ry % + Y^0.YY-% P* _ Signature _- ' ' i Date q " to - c7 0