HomeMy WebLinkAbout3407 Rolling Green Dr - Applications/Gas - Log, Line, Pipe - 12/05/2013DEC-05-2013(THU) 14:55
P. 001 /001
City of planning, Development & Transportation
Fort Collins N. College Ave P.O. Dos SBD
For
�- Fort Collins, CO 80524
Phone 970-q16-2740 Fax 224-61.34
OVER-THE-COUNTER PERMITS ONLY
This application is to be usod to apply for the following pormiis only (check all that apply). Alr ing
Demolillon (Interior non-structural) Electrical Alteration (net service change) Gas Lighter(Gas Lo
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
manufacturor)•
Completeall aoalicablo information on the application. Incomplete apolicationswill not be accepted,
Application # ���-� Date
rwwkne use only
lob Site Address riNafine) value of Construction (labor, materials, profit)
Property owner Name Address Oty/State &USZ� Zjp Phone 9 f /
aN C L�t 3ym tzou.tMIS C,OrCN 0A- P6(4co . 9
Applicant Name Address City)State
Zip Phone
Contractor Address City/state ZIP Phone
r-ta-c-� supioiwv V2tJgsLiac Pe �F_G/ca NZS7L4 4%,cA
Contractor City of Ft Collins Sales Tax # Are you paying Axes here or by report? Here
Saks4W mrr4erIcmquh-ebya/1mne'aamm }�' � Are you paying with your trust account? YeszIr
Is this a residential or tesIdentl Commercial
If residential, is it: SIn le Fa Condo/townhome (single family attached) Duplex
Multifamily (apartment) Garage
If commercial, is It: Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (expl
Is this building 50 years of age or more? Yes tui Y= YOU may need to =taCCyl�YoriC Preservation
If this Is for a demolition permit, what year was the—tiMining constructed?
Ifprior to I977 you w7l nerDan asbesws aze!;Vn r r tosubmit with this application,
i of work
a NZ,
*6LC;
w I r— �.�.11 _ O L. vu C CV N `if lawn sprirlklertbackftpeanerneb
must list licensed plumber. If Fr;t•dme A/C, must list licensed electrician.
Subcontraetsrs: List the Wn7 ny name or Py of Ft Copin5 license 0
necaiden 12' L1 � CZWI SLC-CTy I
Vlumbc M nlcal Roofer,:—. Other
I hereby acknowledge that I have read this apalicarlon and state that the above Information Is complete and correct- L agree to
comply with all requirements Contained herein and city ordlmnces and sbte laws regulating bullaing construction, x know that a
permitis notvalid until It has been paid and Issued.
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avnttwnt: '1'�
Print Name Sipnatur
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