HomeMy WebLinkAbout113 N Sherwood St - Applications/Gas - Log, Line, Pipe - 10/26/2011 (2)NOV-03-201)(THU) 09:41
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City of
Z `r Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort 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-voltalc
Ventilation Water Heater Water Une WcodlPellet Stove (must be EPA certllled, provlde.make, model and
manufaclurer).
Complete all applicable informaattiionn on the application. Incomplete applications will not be accepted.
Application # ?11 l — -Date
o �s only "
Job Site Address (rcqunrd) Value of Construction (labor, materials, profit)
� t3 � . s 1�=2waoD 31ob ,00
Property Owner Name Address Clty/State Zip Phone
R�ND`1 CvG2f=T It3 r) st+�(L►�.oCO �i`GouarJS 9D521 Z14-Z395
Applicant Name Address Gty/State ZIP Phone
Contractor Address City/State ZIP Phone
wESTEZr-) )Kbg R"%SP`9-E F_% c.0u.1NS &0 21N L195--96-7�
Contractor City of FL Collins Sales Tax Are you paying taxes here or by report? Here o
-Saks MrnumbvISrMurredbyafieono- uo�s Are you paying with your trust account? Yes
Is this a residential or Comm ect? sl n Commercial
If resldentlal, Is It I Famil Deta ed Condo/townhome (single family attached) Duplex
MultlramIly (apartment) Garage
If commercial, Is It: Bank Bar • Church Hotel/Motel Medical office Orrice Retail
Restaurant Ot�plaln)
Le this building 50 years of age or Marc? Yes No If)= ypumaynmed to contactNistvric servatiOn
If this Is for a demolition permit, what year was the building Constructed?
ffprior to 1975, you will need an asbestos assessment to Submit with this application.
Description of work t N s 74-tom b % rL G7L:r v e,--t' �-.c,S sTpv E A-"t�
Gr�.S L-1 ti a
*If lawn sprinkler/backnow preventcr, must list licensed plumber. Tr firt.tlme A/C, must list licensed electrician.
Subcontractors: list to company name or CIty of R Collins license Ay
hleeuielan- Plumber.
Mechanical.. Roafcr. Other.
I hereby acknowledge that t 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:� 'bA1
Print
Name: I•7 Slgnaturc�-,C/ Ir..�/^ (d^Z(o--It
Date