HomeMy WebLinkAbout1110 W Mountain Ave - Applications/Reroof - 03/27/2012City/ of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins Fort Collins, CO 80524
140'�� Phone 970-416-2740 Fax 224-6134 6
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 ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application # /31e;)LC) /5S
For office use only
Incomplete applicati ns wi not be accepted.
Date G7 / 2
Job Site Address (required) Value of Construction (labor, materials, profit)
Pr erty Owner Name
Address City/Sty
Zip
Phone
Ap licant Name
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Address City/State
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Zip
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Phone
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Contractor Lic #
Address City/State
Zip
Phone
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Contractor City of Ft. Collins Sales Tax
# Are you paying taxes here or by report?Here ❑ Report
sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes &No
Is this a residential or commercial project? 4!ZResidential ❑ Commercial
If residential, is it: J3-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 SO years of age or more? 10Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If phor to 1975, you w/11 need an asbestos assessment to submit with this application.
Description 9f work 1ht / 70 .0' Pe,174 lkf / 35rl `
*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 !� 197 / 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: L5/�J���/y�
`fir( V Signature Date