HomeMy WebLinkAbout5212 Parkway Cir W - Applications/Reroof - 12/05/2011City of
Fort Collins , s
OVER-THE-COUNTER
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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 ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the appy ation. Incomplete applications will not be accepted.
Application #SDate
For ofice use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State Zip Phone
A pliant Name
Address
/State Zip Phone
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Contractor
Address
City/State Zip Phone
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Contractor City of Ft. Collins
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Are you paying taxes here or by report? ❑ Here Q Report
sales tar number rs req Bred by a//
Are you paying with your trust account? Yes ❑ No
40 917
Is this a residential or commercial project? 0 Residential ❑ Commercial
If residential, is it: AtSingle 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 MLNo 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 MY need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/baddiow preventer, must list licensed plumber. If first-time A/C, must list4iobnsed electrician.
Subcontractors: List the company name or Gty of Ft Collins license #
Electrician Plumber Mechanical Roofer 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 mnstrudion. I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Nam 1 . /r eS�K Signature r
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