HomeMy WebLinkAbout2290 E Prospect Rd - Applications/Reroof - 12/06/2011city of
Foci 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 kRoofing ❑ 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 application. Incomplete applications will not be accepted.
Application # B& L *�
For office use only
Date 0 30�11 1 z�6:1
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address City/State Zip - Ph ne
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Applicant Name
Address City/State Zip 'Phone
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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? ,Here ❑ Report
Sales tax number is wuired by all contractors
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Are you paying with your trust account? ❑ Yes /.No
Is this a residential or commercial project? ❑ Residential A Commercial
If residential; is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) : ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office Aoffice ❑ Retail
0 Restaurant . ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes []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.
Description of work ' 4v- I Q ox 6 S vAre - o-r VLcrb— {sf mtea4el-,'al Oh t-barC,
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber Mechanical Roofer — / 3 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: !
Print Name:�k r i S� n MC IPIa 1i0 1 _ Signature to 11'' Qk--
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