HomeMy WebLinkAbout524 E Magnolia St - Applications/Gas - Log, Line, Pipe - 11/18/2011NOV-18-2011(FRI) 11:33
P. 001 /001
City of Planning, Development & Transportation
281 N. College Ave P.O. Box 5Bt)
Fort Collins Fort Collins, CO BOS24
Phone 970-416.2790 Fax 224.6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be usod 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 409
Heating Unit Lawn Sprinkler Mobile Home replacement Roofing Sewer Line Photo -voltaic
Ventilation Water Healer Water Line WoodlPollet Stove (must be EPA certlfled, provide make, model and manufacturer), n
Complete all malleable information on the application. Incomplete applications will
Application # \\ "g
For orrice use only
no a accooted.
Date
Job Site Address (rWalird) material,l Value of Construction (labor,
I � ( �, profit)
Property Owner Name v ate
Address Clty/State ZIP Phone
_ _ � I _\ _ ham+ , r J%A .� _
Applicant Name Address City/State ZIP Phone
Contractor Address
t . _ � �' r aN/state 21p Phone
Contractor City of Ft Collins Sales Tax k
Are you paying taxes here or by report? Here Report
SaksGrxnronbersrryutr�yoy�NQ71�a Are you paying with your trust account? Yes No
Is this a residential or comm cial ro ect? Resldentla Commercial
1f resldentlal, Is IC. n le mil Detac r Condo/townhome (single family attached) Duplex
Multifamily (apartment) Garage
If commercial, Is It: Bank Bar Church Hotei/Motel Medlcal office Office Retail
Restaurant Other (explain)
Is this building 50 years of age or more? Yes No tfye,; youmayneed to contactHlstoricPnetf-ervaGon
If this Is for a demolition permit, what year was the building constructed?
if pnor to 1975, yvu will Medan asbestos as r 1sment to submit with this application,
of
*rf lawn sprinkler/backnow prevenrer, must list licensed plumber, If First-time A/C, must list licensed electrician.
Subcontractors: let the mmpany name or City of pe ColiinS license <
EloctrlClan1^ Plumber Mcchanieal -� Roofer . Other.
I hereby acknowledge that I have read this application and state that the above Information I, complete and correct. C agree to
comply with all reclulrements contained hereln and city ordinances and state laws regulating building construction. I know that a
permit is notvalid until it has been paid and issued.
Applicant I l I
Print Name ��„R����Ci� Signature � DatQ �,L