HomeMy WebLinkAbout6570 Portner Rd - Applications/Addition or Alteration - 09/09/2013Fort Collins
Planning, Development & Transportation
281 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
❑ 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 # 6tzoq & 7 Date 9/9/1 -6
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
o $ 10 i2s 50
Property Owner Name
Address City/State Zip
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Phone
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Applicant Name
Address
City/State Zip
Phone
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Contractor Lic #
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Address
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City/State Zip
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Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here ❑ Report
Saiestax number isrequired byall contractors.
Are you paying with your trust account? ❑ Yes
❑ No N,1
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&otel ❑ Medical office ❑ Office ❑ Retail - 1 • \ y
❑ Restaurant 0 Other (explain) _I fa .n� �o,.� %7-MC-7 V . �, �,,.o, �o,c �
Is this building 50 years of age or more? ❑ Yes IRl No If yes, you may neegf to contact Historic Pre ruation
If this is for a demolition permit, what year was the building constructed? M %&
If prior to 1975, you will need an asbestos assessment to submit with this application.
n of work
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*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 # 7��/�li
Electrician CO,rI T mti1aec..Plumber () I r ov. W ty Mechanical u I % Roofer K/A— 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: Print Name: R 1/
o Ln L< 2c_1N�VEy Signature�j� Date
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