HomeMy WebLinkAbout636 Cheyenne Dr - Applications/Gas - Log, Line, Pipe - 02/21/2014City.of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
�Collins Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
3`A - °d OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Condftio 'ng
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter j:-Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line-' ❑Photo -voltaic __ff
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application # &gC)0gs3
For ofte use only
Incomplete applications i7ll%ot be accepted.
Date �2LI l
lob Site Add (required) Value of Construction (labor, materials, profit)
Property Owner Name Address City/State Zip
CO�.Z'v CJ 1 e1/I i� 0'6 J6
Phone(9-'�)
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Applicant Name S dddresssJ �—m City/ fate Zip C �Phpne
tractor Lic # Address C�tate . Zip O:VdPhone]
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41 i �s�
I ►'1 C d � 0 ! O
a1 3 -79�
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here
Report
Sales tax numberisrequiredbyallWnb=M. Are you paying with your trust account? ❑ Yes
No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: Single 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 ';EtNo If yes, you may need to contact Historic Preservai fon
If this Is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you will need an asbestos assessment to submit with this application.
*If lawn sprinkler/baddiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Ust the company name or Gty of ft Collins license #
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 building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Name: SignatureDate a