HomeMy WebLinkAbout544 Jansen Dr - Applications/Reroof - 02/01/201202/01/2012 06:05 3036991105 NORKAP CONSTRUCTION PAGE 02/02
C' Of Planning, Development &Transportation
Fort Collins For N. College Ave P.O. Box 580
Fort Collins, CO 60524
Phone 970-41616-2740 Fax 2246134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). O 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 ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applicationn$ will
not be accepted.
Application # b l a a --I Date -2h
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
S q Joinsen r.
$ �-
Property Owner Name
City/State Zip
Phone
ter. rC±a e
( �Address
( Jrtns'eii
Dc 21tris a- 25
D- - KY
Applicant Name
Address
City/State Zip
Phone
Contractor
Address
City/State Zip
Phone.
A]Akap C4hskJc4u-N 156
S �A [i A
ror•A co Doi
6-20- 011
Contractor City of Ft_ Collins Sales Tax
#
Are you paying taxes here or by report?
❑ Here ❑ Report
Sales taxnumber isrequlredbyall con&actors
Are you paying with your trust account?
❑ Yes ❑ No
is this a residential or commercial project? b(pesidential ❑ Commercial
If residential, is it: U`Single Family Detached ❑ Condo/townhome (single family attached) O Duplex
O Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank O Bar ❑ Church 13 Hotel/Motel ❑ Medical office ❑ Office O Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? O Yes ffi(No 0yes, ynumay need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
rfpnor 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 Ftcollinslicense0
Elearician 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: I (� ]
Print Name: Sfe—
q IT / Signature
Date 2 I I x