HomeMy WebLinkAbout2225 Pole Pine Ln - Applications/Reroof - 10/24/20111o: [Luni: rouLcy l]LLG111 au-u 11 V.11.11. F. L U♦ L
ea# �¢ Planning, Development & Transportation
Y 281 N. College Ave P.O. Box 580
CollinsFort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile. Home replacement'Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater D Water Line ❑ 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.
Application # �� O qGi 51 Date Io. U3
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
2.Zr1 1ble- 'PlYli'. _�i�l{;
A (_P2.t.U,Lx;
Property Owner Name Address City/State Zip Phone
(110.
Jc.a,i-) ,e- ac lnf't)i;vt l2'1.,`�
f�ol.c°: F;r�e, Ln. r-nrzI 'Stf�JLL? <P�2.5i2b
Applicant Name Address City/State Zip Phone
?15/o
u:).�'.}-t�AtC Nrive4. Clj zoc
Contractor Address City/State Zip Phone
Ckll_'.n }- Cam= ,fit'; C 3 3C3,'l r.=�:"lieCo-D
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ,fHere ❑ Report
Sales tax number is required by a#mntractors.
Are you paying with your trust account? ❑ Yes No
Is this a residential or commercial project? tResidential ❑ Commercial
If residential, is it: aSingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain) _
Is this building 50 years of age or more? ❑ Yes 1'No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the companyname or City of fit Collins license ,#
Electrician Plumber Mechanical Roofer') S/' 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 lY-1;
Print Name:((! � l.d � ti i� i, Signature Date 10 -- / �