HomeMy WebLinkAbout843 Kingston Dr - Applications/Water Heater - 08/19/2013rt Collins
PMMOW
21M M. CIOW Ave P.O. Bux SIM
Fort Coles, 00 W524
Phone 9M-a6-2740 Fax 224-6134
OVER—TH&COUMR PE MffS ONLY
This applicadon iota be used fo apply %r %e fiofivgft* p wdy (deck al! ftajt apply). C] Air CoriMOWng
❑ Demon (tlrtwior normfttM� Cl em*W A (rot she dwW) 0 Gas Lighter ❑ Gas Log
❑ HeaWN wta 13LmnSpmklerl3MobReHonorepbcMxwd DRooft USewwUne ❑ phobv�
❑ Ventilation Mwater Healer ❑ Water Lbw ❑ Woodreft smw (unut be 6PA cam, pvAds make; model and
manij.
Complu'ds au applicable adorndton an the agwilcabom appOcaffews w M not be wed.
:Applica on # EJ 73 pate 6-11 -l3
lob SRO Addrum (mil Valve of Cauirodion (tabor, i 16 P,W
y3 $
Property Owner Name Address
ter/State .Zip
Phone
�y3�
c�6szs-
zz�_zJAppk"��
me Address
OLy/State ZP
Phone
C nbactpr LIC # Address
`a7/aK . zip -
Phone
13) A 1i2CKSf
J* Cb /• e,& &t�SZ-I
5i��- zGoS
Conh-admr City of Ft Collie: Sales Tax #
Are you paying fialaes here or by report?
CI Here Mepw t _
tmrarw*arAmgw edbyaffaw*acmm
Are you paAV wdh your bust aamurd?
EPYes ❑' Ko
ZZS'$'7
is this a residerag or a mmmN p �..dal
If resided, is it ❑ Slagle Fan* DeWmd ❑ ONWD(04e fauY ❑ bq*m
ff amunadw, is ► : Q Sank ❑ aar IC3 chuKib O tlowVmaW ❑ pledle d oM a Oft m 0 Retail
❑ ReSMuatrt ❑ Other (ex*ut)
Is this building so yews of age or mare? O Yes a mo
If this is for a dot permit what year was the bt nft omigmcwq
�P�m197Sz yor► r�/RaedaR,ttLDsrd�rn$rw�i il,�s
„ mrvu-4ummwlummuw ZAe18W, mlQ Mt Qt
ff fast thre AIr. mist lit pCensed ekXbjCMn.
Suboamtractors L&ffwanpynallreoravemasws a►ae#
BecbWm Plurruber pt
.RoaW. Otlrer
w tlratl taus read thfs i arm stae that the above women Fs aompkMe and gorse_ i agree m
canply ft all rew*wmerftaxtakied Imeb and dtycedirames and state kmreWala ft buTideug amsbucam. I know Brat a
tmm"rmtvalra uffIffl arm teen Valid and ibmed.
APPTicarrh - c -
tDate