HomeMy WebLinkAbout233 Clover Ln - Applications/Reroof - 11/14/2011NOV/14/2011/M0N 01:07 PM
FAX No.
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P. 006
Ci Of Planning, Development & Transportation
FtY} 281 N. College Ave P_O, Box S80
OrI Collins Fort Collins, CO 60524
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
Cl Heating Unit ❑ Lawn Sprinkler t7 Mobile Home replacement fiO Roofing ❑ Sewer Line O Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ 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 #fi � (� 103-1 3 Date
Far office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name Address
City/State Zip
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Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? X Here
❑ Report
Sales tax number isiequiredbya0crontradors
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Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or commercial project? ❑ Residential Q'Commercial
If residential, is it: GLSfngle 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 ❑ No Ifyes, 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 VF.;uoJ 1:_ i A_n7,nJ(, '-n- Qi;!!e4_ {- f�e_PC, A(,e-.
*If lawn sprinkler/backflow preventer, must list Ilcerued plumber. If first-time A/C, must list licensed electrlcian.
Subcontractors: List 65e companyname or City of Ft Collins license 0
Electrician Plumber Mechanical Roofer
Other
I hereby acknowledge that I have read this application and state thatthe 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.
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Applicant:
Print Name: 111 1 �_ ,fli Signature Date
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