HomeMy WebLinkAbout221 Lyons St - Applications/Other - 01/30/2012Cityof Planning, Development & Transportation
281 N. College Ave P.O. Box 580
F6r1�} 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 Homy replacement ❑ Roofing ❑ Sewer Line ❑ Photo-voltaic-
0 Ventilation ❑ Water Heater ❑ Water Line lirWood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicabl information on the application.
Application # -2-- 1Y 0 d
For o e use only
Incomplete applications will not be accepted.
Date I -So-( Z
Job Site Address (required) Value of Construction (labor, materials, profit)
Z2-t W. 4L �-nS $ %n 0_0.�
Property Owner Name
Address
City/State
Zip,
Phone
S 4 L s 221
o n s
F�. GIc,�S co
$0' z
�70 -5 - / (2
Applicant Name
Address
City/State
Zip
Phone
AL_� E2:S
Contractor Lic #
Address
City/State
Zip
Phone
fP l4yg
(a.o.86x 2�2 of F�_ Ca[cru5 Co
?SS2-7
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
Sales tax number is required by all con&actors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? ErResidential ❑ Commercial
If residential, is it: [TSingle 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 If yes, you may need to contact Historic Preservatio
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
*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: , ` l "'` �'_� s Signature �� Date / - 2--