HomeMy WebLinkAbout1654 Greenstone Trl - Applications/Water Heater - 05/12/2014From:
City of
05/12/2014 07:51 #064 P.002/002
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Planning, Development & Transportation
281 N. College Ave F.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) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ater 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.
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Application #1 _I 2Q Z-a I Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
3,
Property Owner Name Address City/State Zi
I ,., , _ p Phone
Applicant Name Address City/State Zip Phone
Contractor Address
` 1 „ A City/State Zip Phone
Contractor City of Ft. Collins Sales Tax # a
Are you paying taxes here or by report? IrHere Report
sales tar number cs repuiredbyall mn&adors: Are you paying with your trust account? 9yes 13 No
Is this a residential or commercial project? �esidentlal ❑ Commercial
If residential, is it: mgle 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 50 years of age or more? ❑ Yes ❑ No ffyes, you mayneed to contactHistor/cPreservation
If this Is for a demolitlon permit, what year was the building constructed?
if prlor to 1975, you wi// need an asbestos assessment to submit with this app!/pbon.
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 Cty of H Collins license #
Electridan 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: n\CDXP tom+: o)"', Signature R �_ Date