HomeMy WebLinkAbout501 Affirmed Ct - Applications/Reroof - 10/19/2011City of F6rt Collins'?� Planning, Deer
r✓ F281 N.ort Coil ol�e Ave e� p pt� 80aP�tation
ns, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS
This application is to be used to apply for the followln �N�Y
❑ Demolition (interior non-structural) ❑Electrical Alteration (not sits only
�aneck all that a
❑ Heating Unit ❑Lawn Sprinkler ❑Mobile Home replacement p Roofing ❑ ply?. Q Air Conditioning
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ WoodlPeilet change) ❑Gas Lighter ❑Gas Log
9 Sewer Line ❑ Photo -voltaic
�ufscturer). Stove (must be EPA certified, provide make, mode1
and
Complete all applicable information on the application. Incomplete applications will not be
accepted.
Application #
e use only Date
lob Site Adder u/J
�lue Of Construction (labor, materials, profit)
Property Owner Name e0c.
7Adre,,,sCity/State Phone
h one
App. t Name Address /
_
City/Sta#e zip1411 i?hone
Address City/State 1-
Zip Phone
ConCity of Ft. Collins Sales Tax # Are you Raying taxes bane or a
SaAPs tax nionbw,& repi,�by aye
by +report
�e,you paying with your trust � Here �' Report.
account: ❑ yes )(No
Is this a residential or commercial project?
If residential, is it: ❑ Single Family Detached dentist ❑ Commercial
❑ Multifamily (apartment) 0 Garage ownhome (single family attached) L3 Duplex
If commercial, is it: ❑ Bank ❑ gar ❑ (lurch
Restaurant ❑ MOB/Motel ❑ Medical office ❑
Is this building50 ❑Other (�plai) Owe ❑Retail
Years of age or more. ❑ Yes�No If es
If this is fur a dim"Ition perm What year was Y , you may nettd to m
Ifprio�to-1975 ildingconstructed? ntactH/sit�iicP�vatfon
J�ou will nod an asbestos as s9went to submit wfffi dhis• app//cation
Description of work
*If lawn sprinkler•/backflow, preventer� must list li '
Subcontractors: �� � Plumber. If first-time NC, must list licensed
comamY name Or Oty of Fit Col&6 /Icansrr #
Elearkun Plumbs
Rode- Ckt�ar
I hereby acknowledge that I have read this applicationrequirements and state that the above info
permit is not valid unto it has been herein and city ordinances and rulating b complete sandtru correct. I agree � �� and ��, state laws regulating building core. I know that a
r /
APPikent:
Print Name:,-
signatu
Date