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HDIAEOWNERJBUILDER AFFIDAVIT
I/we, d`�Q as owner(s) of record of the property located
Tease print)
at: ll 6e0.Fl SFort Collins, Colorado, hereby declare and attest to
(please print)
the following: (please checkeltherA orB)
❑ A. I am/ we are acting on my/our behalf for the purpose of obtaining a building permit and
personally constructing my/our home. The home to be constructed is on the above property and
will be my/our primary residence. I/we have not personally constructed any other new home in Fort
Collins city limits within the past 24-month period.
E( K I am/we are acting on my/our behalf for the purpose of obtaining a building permit and
personally constructing an alteration or addition to my/our home. The home to be altered is on the
above property and is my/our personal residence.
I am/we are personally performing all of the work, or will be continuously supervising unpaid volunteers.
The work is directly related to the construction of the above referenced home, which is described more
fully on Permit Application # (obtained from Building and Zoning
Office). I/we understand that any persons or agents contracted to perform structural wood -framing,
plumbing, HVAC, electrical work, roofing or cast -in -place structural concrete work, MUST BE licensed
contractors in accordance with the regulation of the City.of Fort Collins.
IJwe understand that failure to comply with any of the above conditions may result in revocation of
any permits associated with the above Permit Application number, forfeiture of any fees that have been
collected, a Stop Work Order and a court summons.
Sign in the presence of a Notary Public
Owner
Owner
T fo egoing Affidavit was acknowledged before me on this a? day of"+
ii'OO� (month, year)by TMnIC AiGe- l�LooN
Witness my hand and official seal
lAy commission expires:
No"tzry Public
281 N'Dr[h Cullege _'Venue ° P.O. Bo): 380 ° Fort Collins, CO S0522-05o0 • (970) ?211-6760 • F-'J: (970) 24-613`4