HomeMy WebLinkAbout5232 Southern Cross Ln - Applications/Plumbing - 09/26/2011Cky
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Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-4164740 Fax Z24-6134
OVER-THE-COUNTER PERMITS ONLY
This, application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) 0 Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler 0 Mobile Home replacement ❑ Roofing 0 Sewer Line ❑ Photo -voltaic
0 Ventilation 0 Water Heater XWater Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all appy a le information on the application. Incomplete applications will not be accepted.
A Application # _ Date V -z�
For.ol�ce u only 1 �1 �% %�
Sob Site Address (required) ss l_ h N 1 Value of Construction (labor, materials, profit)
.� _ . sc> c>'j ti G�lJ C a D
Property Owner Name
Address Gty/State Tip
Phone
grto-s�v�lll
Applicant Name
Address City/State Zip
Phone
�t C-�cz-a csE' .
-mac .45 A-ao L.,�
Contractor Lic #
Address City/State Zip
Phone
Contractor City of FL Collins Sales Tax
# Are you paying taxes here or by report?
❑ Here 0 Report
Sales tax numberrsrequiredbya//Wnbacwrs
Are you paying with your trust. account?
.0 Yes ❑ No
.Is this a residential or commercial project? M Residential ❑ Commercial
If residential, is it: M Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it ❑ Bank. [3 Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 yearn of age or more? i] Yes Jl No If yes, you may need to contact Historic Prnservaton
If this is for a demolition permit, what year was the building constructed?
If prior.to 1975, you w111 need an asbestos assessment to submit with this ap licatfon.
Description of work P .t_Nc -. S N w tA (ewe- i tS
Lt;yEL 2oc�M - -
*If lawn sprinkler/baddlow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician..
Subcontractors: List byee company name or City of Ft Collins license 0
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 containedherein 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:BN�kU--'O 1 �-L �� Signature Date