HomeMy WebLinkAbout1919 Connecticut Dr - Applications/Reroof - 09/14/2011Cityci
Flirt f tins
Planning, (Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 8D524
Phone 970-416-2740 Fax 224-6134
This application is to be used to apply for the following permits only (check all that apply). O Air Conditioning
O Demolition (Interior non-structural)- O Electrical Alteration (not service change) O Gas Lighter ❑ Gas Log
O Heating Unit a Lawn Spdrilde r O Mobile Home replacement ❑ Roofing O Sewer Line ❑ Photo -voltaic
O Ventilation ❑ Water Heater Il Water Line O Wood/Pellet Stove (must be EPA cerfftd, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application #Y, � l oA onb Date
For o1ACe use only l Ae l _ F-i I—
Job Site Address (requlve)
Value of Construction (labor, materials, pro it)
r
Property Owner Name Address
City/State Zip
Phone C976
Scum e
Applicant ,Name ress City/State Zip
�l(55 t aSewell A7►e,'Swi-i-C tloo
L•izoL iieCd
Phone
v�_ nvFr, �t�
Roaa-� 7
01 -568
Contractor ��j f� �7�U (/ Address Ci JSt to ZIP
6 Up i - �S P — -7ne tIBC,y
Phone
o) �6$
Contractor City of Ft &Illns Sales Tax #
salestarnumb.(e�jquredby lamGvxtors.
Are you paying taxes here or by report?
VHere Report
Are you paying with your trust account?
D Yes No
Is this a residential or commercial pro'ect? ❑ Residential ❑ Commercial
If residential, is it: Single Family Detached ❑ Condo/townhome (single f2mily attached) ❑ Duplex
i Q Multifamily (apartment) ❑Garage
j If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office C7 Office CI Retail
I ❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? O Yes fd, No If yes, you may need to contact H/stvric Preservation
If this is for a demolition permit, what year was the building constructed?
If pNaf t.1175, you P41 need an asbalm assessment to submit with this appimatyen,
Description of work Y-4
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Sulrconbaebors: LAtthe cvmpanynameorCity ofFrCollins/icensge
I Electrician Phm jer � _ Mownipl__ Roofer R-2 -235 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 city ordinances and state laws regulating building construction. I know that a
permit Is not valid until it has been paid and issued.
Applicant I I/Q I.,,� 1/1
Print Name: � signature �'1 0_e pate "l