HomeMy WebLinkAbout405 Mathews St - Applications/Mechanical - 01/18/2012CityOf Planning, Development & Transportation
Fr281 N. College Ave P.O.-Box 580
01 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). ❑ 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 informationloop the application. Incomplete applications will not be accepted.
Application # DEDD ' I t
For ofce use only I� a�jj
Job Site Address (required) Value of Construction (labor, materials, profit)
q 6-S MafLw s S t - R 6/6;15 1 $ / / ' oun
Property Owner Name
Address
City/State Zip
Phone
0r
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-da.
Applican Name J
Address
City/State Zip
Phone
Contractor Lic #
Address
City/State Zip
Phone 9 7 D
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Contr ctor City of Ft. Col ns Sales Tax
Are you paying taxes here or by report?
❑ Here Report
sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? ❑ Residential 0 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 T-AS I ( 110,W b 0i(wr
*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 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:P'14�Signature acv,," 1 U"'-- Date t $' 1 Z