HomeMy WebLinkAbout2330 Rollingwood Dr - Applications/Gas - Log, Line, Pipe - 11/08/2013NOV-08-2013(FRI) 18:10
P. 001 /001
City of Planning, Development & Transportation
FN. College Ave .p.0. Box 590
F&I COtt'n$ or
Fort Collins, CO 130524
Phone 970-416-274o Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application Is to be used to apply for the following pormits only (chock all that apply). Air Conditioning
Demollllon (interior non-structural) Electrical Alteration (not service change) Gas Lighter Gas Log
Heating Unit Lawn Sprinkler Mobile Home replacement Roofing Sewer Line Photo-voltalc
Venlllatlon Water Heater Water Line Waod/pellet SIM (must be EPA certified, provide make, model and
manufacturer).
Complateail applicablo information on the application.
Application # 3 13060
Mr office ase only
Job Site Address (required)
Z3"30 (10U.1N6
Property Owner Name
Applicant Name
Address
�- 23
Ineomolete aoolicationswill not be accepted,
Date 019 IVO-V 2.CD( 3
Value of Construction (labor, materials, profit)
Clty/State Zip Phone ` TO
Z11. 535
Address OWState
21P . -Phone
Contractor Address dty/Sta
te ZIP Phone
Ut%C'`;; . K`1a.4 � SOP47LV 1408 gk%j(a,,,iDC I>Q rXZS24 97-04%.9t
Contractor City of Ft Collins Sales Tax # Are you paying taxes here or by report? Here A
Sal"LsrnumDrrtsrzpulredhYallmna�c7o�x 14 I?iT-� Are you paying with your trust account? - Yes
Is this a re;identlal or co er:c I , 1raj M W Commercial
If resideritial, Is It: Single Family Detached Condo/townhame (single family attached) Duplex
u rn y apartment) Garage
It commercial, Is it: Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this bulfdiny so years of age or more? Yes [�oIty44 Irou may need to contactM/=ni: pres_pvyr on
If this Is for a demolition permit, what year was the�,iuklding constructed?
Ifprior to X973,, yno will freed an asbegros J"eeMenr to submit With this applicapan.
of work e
i N5FV:,
"If lawn sprinkler/backflow preventer, must list licensed plumber. If rirst time A/c:, must list licensed electrician.
Subcontractors: list the company name ar IVry of Fr Collins rrccnsc
l:ieetrlClan�,�, Plumber p .
echanleal�„ poorer. 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, x know that o
permit is notvalid until It has been paid and Issued.
�'}-2nt%�Lo IN254GrtIw�r�C��
Applicant;
Print Namc: W-r=�
5lgnatu Date 2.01?J