HomeMy WebLinkAbout821 Province Rd - Affidavits/Homeowner - 12/28/2010City of
Flirt Collins
Planning, Development. and Transportation
PO Box 580
281 N College Ave
Ft Collins, CO 80524
970-221-6760 phone 970-224-6134fax
I/we, t_1 , as owner(s) of record of the property located
At: �l�dt/I //�� , Fort Collins, Colorado, hereby declare and attest
to the following: (please check only the one that applies)
❑ 1 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 nay other new homes in the Fort Collins
city limits within the past 24-month period.
,X' 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 house. The house to be altered is on the above
property and is my/our personal residence.
❑ 1 am/we are acting on my/our behalf for the purpose of obtaining a building permit and personally
constructing a non-structural alteration to my/our.attached single family dwelling unit. The house
to be altered is my/our personal residence. I am aware that I/we cannot do any structural,
electrical, plumbing ore mechanical work and must hire contractors/subcontractors who are
currently licensed and insures with the City of Fort Collins.
I am/we are personally prng►�allfof Irkr sill be continuously supervising unpaid volunteers.
The work is direct) relat o eo of tie , bove referenced home, which is described more fully
on Permit Application # (obtained from Building and Zoning office). I/we
understand that any person(s) or agent(s) 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.
I/we 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 Word Order and a court summons.
Sign in the presence of Notary Public
r
Co-owner
The foregoing Affidavit was acknowledged before me on this Qx Iday of
Q,�p Q-0I 0 (month, year) by �Anc -1gx C- cln� &nSon
Witness my hand and
My commission expire
MY COMMISSION EXPIRES:
April 15, 2012
nnNotary Publi
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