HomeMy WebLinkAbout1019 Boltz Dr - Applications/Reroof - 08/13/2014Clay of
Fort Collins:
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524 ��
Phone 970-416-2740 Fax 224-6134 0�
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 seryic ge) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replaceme Roofi ❑ 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 applications will not be accepted.
Application # f�21 Li C2 Date f 3 A'uCT'
Fo olhce use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
1015 c3��
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Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
City/State Zip
Phone
Cr_ , o r
me CO V6
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Contractor G f"^_ VANA�`"�A�ddress
City/State Zip
Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
Sales tax number Is required by all contractors.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? N' Residential ❑ Commercial
If residential, is it: N Single Family Detached ❑ Condo/townhome (single family attached)
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office
❑ Duplex
❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes P'No If yes, you may need to contact Historic Preservation
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
�23 C7 C"-z-A f.
*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 nyb&rt 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 1 Print Name: K ti� nc i, Signature Date / 3 AU Ca- / t{
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