HomeMy WebLinkAbout2919 Southmoor Dr - Applications/Water Heater - 03/05/2012Ciof
F'®rt Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
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 Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation IX Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all app 'cable information on the application. Incomplete applications will not be accepted.
Application # Date
Folr office use only'
Sob Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State
Zip
Phone
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Applicant Name Address
City/State
Zip
Phone
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Contractor Lic # Address
City/State
Zip
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
Sales tax number isrequired byal/mnbactors:
Are you paying with your trust account?
t! Yes ❑ No
ZZ S5- 7
Is this a residential or commercial project? ® Residential' ❑ Commercial
If residential, is it: & Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
• ❑ Multifamily (apartment) ❑ Garage
If commercial, Is if.. ❑ 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 Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprfar to 1975, you will need an asbestos assessment to submit widr this application.
Description of work e, r
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty 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,-Y- W �wy�So Signature w z
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