HomeMy WebLinkAbout7401 Streamside Dr - Applications/Gas - Log, Line, Pipe - 06/11/2014JUN-11-20140ED) 12:06
P. 001 /001
City cf
�.,F6rt Collins
planning$ Development & Transportation
2B3 N, College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-27g0 Fax 224.6134 I ZI r '7
OVER-THE-COUNTER PIERMiTS ONLY
This application Is to be usod to apply for the following ponnlls only (check all that apply). gaging
Demolition (interior non-structural) Electrical Alteration (not seance change) Gas Lighter Gas Log i
Heating Unit Lawn Sprinkler Mobile Home replacement Rooting Sewer Line Pho
ventilation Water Heater Water Line Wood/Pallet $love (must be EPA certified, provide make, model and
manufactumr).
Complete all applicable information on the application. Incomaleto applications will not be accepted.
Application # 61 Lf bsi 101 Date
For wA9ce use ooy '
Job Site: Address (requ/ma) Value of Construction (labor, materials, pront)
Properly Owner Name Address pty/State Zip Phone
APO Icant Name Address Cty/Sbte ZIP Phone
12WV>✓VfN A&W6�r
Contractor Address Oty/State Zip Phone
Wtl-r�t4 PIQ.�i'l-�Gr* SUP�tl4eQj 12tJC lJ D� r.GIGO 3Q5Z" 92P4 .
Contractor City of Ft Collins Sales Tax # Are you paying taxes here or by report? Here
Mks ornmt r&ra7amebyaAoavuacram I Are you paying with your trust accounts Yes i o
Is this a residential or
if residential, is it:
Commercial
nhame (single family attached) Duplex
Multlfamlly (apartment) Garage
If commercial, Is IC Bank Bar Church Motel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this building so years of age or more? Yes No !ryes you may need to contacrHiawdeAVS&V0Wn
It this Is for a demolition permit, what year was the building constructed?
,rfPd*r 10194 you win need an asbaWs assessment to submit with this jppllnnan.
DeSCHption of work a
"if lawn sprtnZ/badcnow preuenter, must list licensed plumber. If nrSt dyne A/C, must list licensed eleetrlelan.
Subcontractors: W the Gompeny name orQty of Ft Cofrns licenser
eearidan— Plumber , . Mecharikat . Roofer. Other
I nereby admowladge that I have read this application and state that the above Information is complete and correct. t agree to
Comply with all requirements contained herein and city ordinances and state laws regulating building construction. 1 know that a
Permit Is notvalid until it has been paid and Issucd. rn ea4-1-i e,es—t�,eh igv p1Lt �e
Appllcant: {- 1 �I
Print NO me:-~— v, 'Ignature Date (L sI)JVi