HomeMy WebLinkAbout621 Brewer Dr - Applications/Air Conditioner - 01/16/2012_` 177
City f Planning, Development & Transportation
�F6y o281 N. College Ave P.O. Box 580
rt 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). ❑ 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 application. Incomplete applications will not be accepted.
Application # 8 I o�-O o� Date
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Y
'5 _ 0o
Property Owner Name
Address
City/State Zip
Phone
Z14/- 375- ,-7i
Applicant Name
Address
Ci /State Zip
Phone
Contractor
Address
City/State Zip
Phone
H i 'r
as-
- �! l
Contractor City d Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
Sales tax number i��rredbyall contractom
Are you paying with your trust account?
❑ Yes No
Is this a residential or commercial project? Residential ❑ 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 ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO 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
*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 ,#
Electriciary_q6�7 LRlumber 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: %% / / r v Signature `(� 72tit-�Qi _!✓tom! Date �(I ���—