HomeMy WebLinkAbout4265 Southshore Ct - Applications/Reroof - 09/19/2011Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-415-2740 Fax 224f 134
OVER-THE-COUNTER PERM17S ONLY
This application is to be used to apply for the following permits only (check all that apply). 0 Air Conditioning
l7 Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter 0 Gas Log
• Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement XRoofing 0 Sewer Line 0 Photo -voltaic
• Ventilation 0 Water Heater 0 Water Line 0 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.
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Application # d �P •
1
Date
ForofJ%e use only
lob Site Address (requked)
Value of Construction labor, materials, profit)
3100
party Owner Name Address
Zip Phone
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L:C�- N K Y� �t•b�'
SSW
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Applicant Name Address
City/Stage Zip Phone
G
Reill fAlpine 'PL
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Contractor b L ` R-'c 3<1 Address -
City/State Zip Phone
Contractor City of FL Collins Sales Tax #
Are you paying taxes here or by report? Here ❑ Report
,sates tax numbe-isieq&mdPyaUmn&dcr M
Are you paying with your trust account? ❑ Yes 0 No
Is this a residential or commercial project? KResidential ❑ Commercial
If residential, is it KSingie Family Detached 0 Condo/townhome (single family attached) ❑ Duplex
Multifamily (apartment) ❑ Garage
If commercial, is it 0 Bank 0 Bar .0 Church ❑ Hotel/Motel _0 Medical office 0 Office 0 Retail
Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ YesNo If yes, you may need to contact Hatoric Presawtion
If this is for a demolition permit, what year was tfie building constructed?
If prior to 1975, you will need an asbesh:is assessment to submit widr Mis appliobom
7
*If lawn sprinider/baddtow prevenber, must list licensed plumber. If first-time A/C, must list licensed electrician..
Subcontractors List the =pry name or Gty of Ft ColAw license #
Electrician. Plumber Mechanical Roofer Other
I hereby admowledge that I have read this application and state that the above information is complete and conecL I agree tD
comply with all requirements contained herein and city ordinances and state laws regulating budding construction. I know that a
permit is nat valid until it has been paid and issued.
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Print Narne.aYl. OLOrHLLA Signature Date _ _