HomeMy WebLinkAbout1931 Dorset Dr - Applications/Water Heater - 06/23/2014City of
F6rt Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
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) Cl Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation gg 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 wi I not be accepted.
Application # I) I U( b3 I ' �1Date
For o>iice use only
Job Site Address (required) Value of Construction (labor, materials, profit)
H3) /�irSc�;?l 7)k"t,- $ leda,
Property Owner Name
Address
City/State Zip
Phone
'
Applicant Name
Address
City/State Zip
Phone
Contractor Lic #
Address
City/State Zip
Phone k1 § /-
�' P S cAr_t mAD�,nc i✓IP-i4Sr i31
/J. cot,.-t; _-2�t Ft%1_7 4�0 .-vSZf
Contractor City of Ft Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here 7-1-.eport
'Wes tax number Is requiredbya1lcontractors
-.
Are you paying with your trust account?
19 Yes ❑ No
ZZ 7
Is this a residential or commercial project? IR Residential ❑ Commercial
If residential, is it: ER 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?
Ifprlor to 1975, you wit/need an asbestos assessment to submit with this applica0'on.
Description of work =, 1 1eA r r .41 C, + e r P. --a jz —
'"If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed'electrician.
Subcontractors: List the company name or Gty 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 ENE W OtiFy�SOY\ Signatur rG�L� �� Date G Z3 za
G. a