HomeMy WebLinkAbout4512 Maxwell Dr - Applications/Furnace - 01/13/2012City Of Planning, Development & Transportation
281 N. FOr't Collins Fort Collins, lCO 80524 P.O. Box sso
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
VI-leating 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 # bI _y 21
1,0
For once use only
Date \
lob Site Address (required)
Value of Construction (labor, materials, profit)
� S11
Property Owner Name Address
City/state Zip Phone
Applicant Name Address
City/State Zip Phone
Contractor Address
City/State Zip Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here 61 Report
sales tax nslmtw IsregL~byall mnbactax
Are you paying with your trust account? KYes q No
Is this a residentia-L.Qr m merclal project? \' Residential ❑ Commercial
ntial; If resideis it: � Single Family Detached ❑ Condo/townhbme (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 50 years of age or more? 0 Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you will need an asbestos assessment to submit with this application.
Description of
*If lawn sprinkler/backnow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City offt Collins license 0
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: f 1
Print Name: ` `" C.o\Q _ M Q)r%Vv,% Signature [\ALalll "ftn Date `3
£00/£00'd OL£q S£:bl ZIOZ/£L/LO £LOZ£600LS JLV XaTTEA a.ipnod:luoJd