HomeMy WebLinkAbout1000 W Prospect Rd - Applications/Gas - Log, Line, Pipe - 10/28/2013City Of Planning, Development & Transportation
Fort Collins For 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). 2 a.
Complete all applicable information on the application. Incomplete applications will not be accepted. , J
Application # g130Sr*d-fS Date
For ofce use only
lob Site Address (required) . Value of Construction (labor, materials, profit)
Property Owner Address
City/State
Zip
Phone
nName
Applicant Name Address
City/State
Zip
Phone
P-o, 3cricX")2-71f
Cedir%'s C�
80�2%
�{70 -G90 Sri�4
Wtractor Lic # Address
t7 �5y
City/State.
Zip
Phone
Pb.&)CV2,"7fS
Co
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
"sere ❑ Report
sales tax number Is required by all contractors.
Are you paying with your trust account?
❑ Yes "o
Is this a residential or co mercial project? 9 Residential ❑ Commercial
If residential, is it: H Single Family Detached ❑ Condo/townhome (single family attached)
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No . If yes, you may need to contact H/storic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you MY need an asbestos assessment to submit with this application.
of work
❑ Duplex
❑ Retail
*If lawn sprinkler/bacldiow 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 A PR P I --"6'JMechanical 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: /
Print Name: �` �� r%� 5 Signature Date