HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Applications/Water Heater - 11/06/2013City0
Fort Collins
Planning, Development UL 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
manufacture
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application #_313 057 y q Date
For office use only
Sob Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner Name
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Address
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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 City/State Zip
1/3 w NUlbeiry 8�921
Phone
`1 � 3 - KN3�
Contractor City of Ft. Collins Sales
Tax #
Are you paying'taxes here or by report?
Here ❑ Report
sales lax number is required by all contractors
Are you paying with your trust account? 0Yes XNo
Is this a residential or commercial project? ❑
If residential, is it: ❑ Single Family Detached
❑ Multifamily (apartment)
Residential ❑ Commercial
A Condo/townhome (single family attached) ❑ Duplex
❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO 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?
If prior to 1975, you will need an asbestos assessment to submitwith this application.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty of Ft Collins license #
Electridan 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.
Prnt Name:/X& �% Signature _14/ ,? Date h /!/�: a24