HomeMy WebLinkAbout2749 Dixon Creek Ln - Applications/Gas - Log, Line, Pipe - 02/14/2012FEB-14-2012(TUE) 11:09
P. 001 /001
Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, Co B0524
Phone 970-416-27g0 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 Rooflng Sewer Line Photo -voltaic
Ventilation Water Heater Water Line Wood/Pellet Stove (must be EPA certlfled, provide make, model and
manufacturer).
Complete all aopllcable Information on the application. Incomplete applications will not
be accopted.
Application # o� ��I
Date 'l l For onrce use only .�
Sob Site Address (requlrrd) Value of ContrIT
bor, flats, profit)
b
Property Owner Name Address City/State ZIP Phone
eA,TC
Applicant Name Address City/State Zip Phone
Contractor Address
qty/54te ZIP Phone
Contractor Oty of Ft Collins Sales Tax /F
Saks Or rtr"ber b• &VujMd byaN mnvacrnrx
Are you paying taxes here or by report? Here
Are you paying with your trust account? Yes
Is this a residential or co. r CMiiILp, a Resid�Ia Commercial
If residential, Is It: �51t]gIC-F,d,t ownhome (single family attached) Duplex
Multlfamlly (apartment) Garage
If commercial, Is it: Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this building so years of age or more? Yes No 160e, you may nerd to contact Historic Preservation
If this Is for a demolition permit, what year was the building constructed?
lfprfor to 1975, you will need an asbestos ass+asment to submit wilt this appMotion,
ption of
" it lawn sprinkler/backnow preventer, must list licensed plumber. If 11 t•time A/C, must list licensed electrician.
Subcontractors: Gist me mmp,7ny n,ome or dry of Fr Collins licensd 0
L•U:ctrlcbn Plumber Mcrhanlral� Roofer. Other.
I hereby acknowledge that I have read this application and state that the above Inrormatlon Is Complete and correct. T agree to
comply with all requirement; contained herein and city ordinances and state laws regulating building construction. I know that a
Permit is notvalld until It has been paid and Issued.
Applicant: 11
Data
Print Name, Q_I� 1'1e �py. Signatur _ C__
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