HomeMy WebLinkAbout1400 Emigh St - Applications/Water Heater - 02/10/201403-06-14;07:34AM; ;970-484-4448 # 3/ 11
Fort Collins
Planning, Development&Transportation
28i N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 22+6134
OVER-THE-COUNTER PERMITS ONLY
This application Is to be used to apply for the following permits only (check all that apply). 11 Air Conditioning
❑ Demolition Onterior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit C3 Lawn Sprinkler 0 Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
O Ventilation dater Heater 11 Water Line ElWood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer). ll __
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application #Z 1401 229 . Date �ZZ
Foro>>rce use only
Job Site Address (required)
L
Value of Construction (labo., materlals, profit)
ralm T
O
Pr, erty Owner Na e
Address
City/State Zip Phone
Pyarlu it
�Q
Applicant Nam
Address
City/State Zip Phone
i � 1 I
. L1 Al
9050 q7,v. 8 • Vl
ntractor
Address
City/state Zip Phone
n e i to i
i
. PL I�1 905a too yk1
Contractor City of FL Collins sales Tax #
Are you paying taxes here or by report? 11 Here Pkeport
Sales taxnurbarZf ul dbyallon"Mrs
Are you paying with your trust account? Yes ❑ No
Is this a residential o�r CpMmenial project? Residential ❑ Commercial
If residential, is it: Single Family Detached ❑ Condo/townhome (single family attached) C3 Duplex
❑ Multifamily (aparbrnent) ❑ 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? 0 Yes ❑ No If yes, you may need to contactH/storic Preservatton
If this is for a demolition permit, what year was the building constructed?
Yprior to 1975, you will npgd an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backFlow preventer, must list licensed plumber. If first-time A/C, must list licensed eletttidan.
Subcontractors: List the company name orCtyofFtCollins llcersse0
Electrldan 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 dty 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: rcr1�'(\ Signature
a -I
pate ��d