HomeMy WebLinkAbout6114 Keswick Ct - Applications/Reroof - 09/27/2011/27/2011 12:10 3032923387 PREMIER
City of Planning, De
/ ^ 6 ` Collin:
Fort Collins, G
Phone 970-41
OVER-THE-COUNTER PERM
This application is to be used to apply for the following permits only (chec
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change
❑ Heating Unit ❑ Lawn Sprinkler O Mobile Home replacement X Roofing (
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be E
manufacturer).
Complete all applicable information on the application. Incomplete applice
Application # 13( 1 01 atI 6c'), Date
For office use only
30b Site Address (requ#ed) Value of Coi
Lei 14 HeS e-K Cp SSoo
Property Owner Name Address City/state
usan �n-wd,rK, kea ps U114 e51A)1'& Ct . F� . C
Applicant Name Address City/State
nn
Contractor Address
rti City/State
Contractor City of Ft. Collins Saba Tax # Are You paying taxes
sales tax numberisrequired by all ro17&ddcrs. Are you paying with )
Is this a residential or commercial project? i$,'Residential ❑Commercial
If residential, is it: XSingle Family Detached ❑ Condo/townhome (single famil,
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church C] Hotel/Motel ❑ Medical office
❑ Restaurant. ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes > (No If yes, y0U may need to
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos a zgessment to Submit With this application.
of work
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must
Subcontractors: Lisr the company name or City of Ft Collins license
Electrician Plumber Mechanical Roc
PAGE 02/04
vent & FranSportation
P.O. 80 580
Fax 214-6134
rS ONLY
all that appl ). ❑ Air Conditioning
❑ Gas Ligh er ❑ Gas Log
Sewer Line D Photo -voltaic
A certified. pr vide make, model and
ons will notbe accepted.
1.11 i30•53
(labor materials, profit)
Zip Phone
90G96 303.IW2.
Zip Phone
ZIP
or by
Phone
� 3o�.a�3.7ta
l<Here ❑ Report
❑ Yes )< No
ached) Duplex
Office ❑ F etail
act Historic Preservai
Other
I hereby acknowledge that I have read this application and State that the above information i complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating wilding constru ion. I know that a
Permit Is not valid until it has been paid and issued.
Applicant:
Print Name: Signature
Date