HomeMy WebLinkAbout2555 S Shields St - Applications/Mechanical - 02/17/2012FROM :NCA FAX NO. :9702299983 Feb. 16 2011 03:05PM P1/2
Planning, Development & Transportation
City of �(% 281 N. College Ave P.O. Box 580
Fort Collins I 'A Fort Collins, CO 80524
/V'� 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). Q�Air Conditionin P
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter i7 Gas Log
El Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation Gl Water Heater ❑Water Line ❑Wood/Pellet Stove (must be EPA certified, provide make, model Imanufacturer).
Complete all applicable information on the application. Incomplete applications will not be acceZd..
Application # 1 �V� 0 �i' Date
For office use only i
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Sob Slte Address (required)
Value of Construction (labor, materiaU
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Properly Owner Name Address
City/State
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Applicant Name Address
City/State Zip Phone
Contractor Address
City/State Zip Phone GI)'O
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Contractor City of Ft. Collins Sales Tax It
Are you paying taxes here or by report? ❑ Here
XReport
5elp<6ixnumber IsMolAredby,7llronmmwrs.
Are you paying with your trust account? I<Yes
❑ No
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Is this a residential or commercial project? ❑ Residential 4TCommercial
If residential, Is It: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar O church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant JZOther (explain) K,rxQtVl C 1Wn
Is this building 50 years of age or more? O Yes gNo 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 Vils appl/cat/on.
Description of work Y- QAxyu Inv V-- I)
KBo-r , 'SQ.H P_ W e,i r f
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: L/st the company name or Cily of R Collins license 0
ElectricianV\,"K " 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: �1
Print Nam 1f['►�R� r� LSign�tu �Q Date
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