HomeMy WebLinkAbout5841 Mercury Dr - Applications/Water and or Sewer - 02/18/2014C' of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
_�®�'t Collins Fort Collins, CO 80524
Phone §70-416-2740 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). O Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) O Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing 0 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 # btLf 00 UT Date.
FX office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State Zip Phone
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Applicant Name
Address
City/State Zip Phone
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Contractor
Address
City/State lip Phone
Contractor City of Ft. Collin
ales Tax #
Are you paying taxes here or by report? ET Here ❑ Report.
Sales tax number Ismqulwdbyall mnbadom
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? 0 Residential ❑ Commercial
If residential, is it: I7'Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage ,
If commercial, is it: ❑ Bank ❑ Bar ❑ Church 0 Hotel/Motel ❑ Medical office ❑ office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes •V No If yes, you may need to contact Histolic Preservation
If this Is for a demolition permit, what year was the building constructed?
Ifpdor to 1975, you will needan asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/bacldlow preventer, must list licensed plumber. If first-time A/C, must List licensed electrician.
Subcontractors: LlstMecompany name orGtyofftCollins 7ibmse0
Electddan . Plumber M?- Lin Mechanical Roofer Other
I hereby admowledge 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.
Print Name: R)D LI Silgnature`c,62