HomeMy WebLinkAbout2819 Mckeag Dr - Applications/Gas - Log, Line, Pipe - 05/29/2014Planning, Development & Transportation
City Of 281 N. College Ave P.O. Box 580
FOI t Collins 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). r Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighte 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 application. Incomplete applications will not be accepted.
Application #
For office use only
Date
Job Site Address (req iced
Value of Con u on (labor materials, profit)
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PTe,rY Owppe��r Name
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A�dd�rress
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Zip
Phone
Appli t Name
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Address
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City/State
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Zip
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Phone
17d SZ'i� 1
Contractor
Address
City/State
Zip
Phone
aS1611(eZA5k
Contractor City of Ft. Collins Sales Tax # .
Sales tax number is required by all contractors.
Are you paying with your trust account?
❑ Yes >eNo
Is this a residential or commercial project? sidential ❑ Commercial
If residential, is it: /D4ingle Family Detac ed ❑ Condo/townhome (single family attached) [I 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 >No if yes, you may need to cWtact Historic Preservation
If this is for a demolition permit, what year was the building constructed? XV
ifprlor to 1975, you will need an asbestos assessment to submit with this application.
Description of
*If lawn sprinkler/backfiow 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 #
Bectridan / 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 construction. I know that a
permit is not valid until it has been paid and issued.
Applicant: //,
Print Name: `' L � Signature
Date S a9'