HomeMy WebLinkAbout3933 Celtic Ln - Applications/Water Heater - 09/16/2013Planning, Development & Transportation
Citrrty}of 281 N. College Ave P.O. Box 580
Fol Collins 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
❑ 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.
Application # 13 l 3 U 4a3
For office use only
Incomplete applications will not be accepted.
Date 9 — l (v— 210 13
Job Site Address (required) Value of Construction (labor, materials, profit)
c, Ke $ SGC)
Property O ner Name
Address
City/State
Zip
Phone
lu eJ
Ap icant Name
Address
City/State
Zip
Phone
f 6tiur
Contractor Lic #
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 isrequired byall contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: ❑ Single 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 may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/baclflow 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 #
Elecbidan 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: �/n ,�^ �j
Print Name: �w �S�yW `� �� °+ S Signature Date �CCCCCC r