HomeMy WebLinkAbout2016 W Lake St - Applications/Furnace - 01/22/2014Frow Poudre Valley Air 9704932073 01/22/2014 13:24 #789 P.001/001
City
}}off I Planning, Development & Transportation
281 N. College'Ave P.
F0r ` Collins Fort Collins, CO 80524 C. Box 580
"�- 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 #_ J �/0C� 3 �! 5 Date
For office use only
lob Site Address (required)
Value of Construction (labor, materials, profit)
3�11
Property Owner Name Address
City/State Zip
Phone
-:4_
Applicant Name Address
City/State zip
Phone
Contractor Address
City/state Zip
Phone
Rou&L\4o" Nor i
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or'by report? ❑ Here
® Report
sales tar number Is rewmd by ali =&adtm.
Are you paying with your trust account? XYes
4 No
Is this a residential or commercial project? Iktesidential ❑ Commercial
If residential; is it: 11iiM6ingle Family Detached ❑ Condo/townhome (single family attached) . ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, Is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes Cl No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpdor to 1975, wu w///.ne+ed an asbestos assessment to submit wlDh this application.
Description of work
*If lawn sprinkler/badffiow preventer, must list licensed plumber. If first-time AIC, must list licensed electriclan.
Subcontractors: List the company name or pty offt Collins&-ense #
Electrician 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 buoding construction. I know that a
permit is not valid until it has been paid and issued.
plicant-
PririntHamei�%kw\Q w. p �
Signature ��A.�.4 . � - Date