HomeMy WebLinkAbout4512 Maxwell Dr - Applications/Water Heater - 02/14/2012City of manning, weveropmem: a r ransporranon
F6r } ` Color s Fort N. College Ave P.O. Box 580
Collins, CO 80524
Phone 970.416-2740740 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-structuraQ ❑ Electrical Alteration (not service change) O Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line.. ❑ Photo -voltaic
❑ Ventilation �IV/ater Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer). lt��
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # S I aOO 8 3-1
For ofte use only
Date -Al m� 17;;L
lob Site Address (repuired)
Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone
5 a
X to & - as
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
a
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here
® Report
Sales awnumber isrequiredbyall mndata rs
Are you paying with your trust account? )KYes
Q No
Is this a residential or commercial project? 1WResidential ❑ Commercial
If residential; is it: Single Family Detach d ❑ 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? O Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
!ff prior to 1975, you willneed an asbestos assessment to submit with this app/icadon.
Description of work
*If lawn sprinlder/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: ` \ Signature t�l. .,A ��— Date
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