HomeMy WebLinkAbout2343 Valley Forge Ave - Applications/Water Heater - 03/08/2012v 0 55/6
Planning, Development & Transportation
Cito��o
281 N. College Ave P.O. Box 580
� F8yt llins Fort Collins, CO 805241o1,0)
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). CJ 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 D Photo -voltaic
❑ Ventilation Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable Inf/o�rmation� on the application. Incomplete applications will not be accepted.
Application #�y l 1 ��-f Date
For office use only
Job Site Address rrequlred)
Value f Construction (labor, materials, profit)
I'�.
Property Owner arl9e V Address
City/State Zip Phone
cobs`P_tew- 14IT Roan ,R�wDQ lio Coe& w5 e08052k -120-21'- 30
A plicant Nape Address
City/State Zip Phone
r ;Same a6he-lo11-4
Fib- 6%-5a-] 3
qoctract Address City/State Zip Phone
o61c&I 5ciS 15rx)0, 852Cb �6b �1�-5a�3
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? WHere ❑ Report
ElNo
sales tax , u�s required by a9 cont>ecmrs.
Are you paying with your trust account? allies
. 40
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 it: ❑ Bank ❑ Bar Cl Church ❑ Hotel/Motel CI Medical office ❑ Office ❑ Retail
❑ Restaurant 0 Other (explain)
Is this building 50 years of age or more? ❑ Yes *No If yes, you may need to contact NistoricPreservation
If this is for a demolition permit, what year was th€ building constructed?
1f prior to 1975, you will need an asbestos assessment to submit with b9is application.
Description of work
WPM
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: L/stthe company name orCity ofFtCollinslicense T
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. Signatu
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