HomeMy WebLinkAbout827 Blondel St - Applications/Gas - Log, Line, Pipe - 12/29/2011DEC-29-2011(THU) 09:58
P. 001 /001
rCi +off II Planning, Development& Transportation
281 N. For ` Chins Fort Collins, CO SOS24 ege Ave P.O.
Box 5B0
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). A.1rC4adLQ0nIng
Demolition (interior non-struclural) Electrical Alteration (not service change) Gas Lighter Gas Lo
Heating Unit Lawn Sprinkler Mobile Home replacement AD
Roofing Sewer Llne Phota-voltaic
Ventilation Water Heater Water Line Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicablo information on the application.
Application #,
For ofrxr use
Incomplete aoollcations wll not be accepted,
Date
Sob Site Address (required) Value f Construction (labor, materials, profit)
Property Owne Name Address Clty/state 21p Phone
Applicant Name Address Clty/State Zip Phone
Contractor Address oty/State zl
%. - % _ _ _ - , c- ,.. _ .� P Phone
Contractor Clty of Ft. Collins Sales Tax # '
41W (Ar J7=bCY K mepaimaby0contraemm
Are you paying taxes here or by report? Here Report
Are you paying with your trust account? Yes No
Is this a residential or commercial project? esidential > Commercial
If residential, Is It: ai'n 1 -• 1r_2etac a Con o/townhome (single hmlly attached) Duplex
Multlfamlly (apartment) Garage
If commercial, Is It: Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this building So years of age or more? Yes No lf) s, Wu may need to contaerH/sroric Preservation
IF this is for a demolition permit, what year was the building constructed?
I(pnor to 1975, YOU wit/ need an asbestos assessment to submit w/th this application,
cation of
"If lawn sprinkler/baekflow preventer, must list Ilcenscd plumber. If Mrst•tlme A/C, must list licensed electrician.
Subcontractors: GLcr the mmPany name or Qry of Fr Collins /iCeWse e
8ectr1d°n---_. Plumber
Mechanical Raofcr. pther..
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 heroin and city ordinances and state laws regulating building construction. Y know that a
Permit Is not valid until it has been paid and Issued.
Applicant 7 1 j I
Print Neme: (� X� Signature ('� tt I ' ,
Date-�..I µJ-