HomeMy WebLinkAbout5421 Northern Lights Dr - Applications/Gas - Log, Line, Pipe - 08/05/2014Planning, Development & Transportation
City of 281 N. College Ave P.O. Box 580
FOI ` COLLI I r� IS Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY 3c� •2S
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 ❑ 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 # �`�J1L4 l Date 5t L
For office use only
Job Site Add (requir d)
C�
alue of Construction (labor, materials, profit)
t o
5'� z oY em
Property Owner Nam Address
City/State Zip
Phone 3'770
ISM ro 5LM
Mn WklyCo
cani me ddress
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City/ to Zip
V ✓ t Cb O
PhoneIrlo 37
Co tract r Address
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City State Zip
Phone?7)U
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: E"Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ 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?
if pnor to 1975, you will need an asbestos assessment to submit with this application.
Description of work Y
*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 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 Named iS6 Signature Date
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