HomeMy WebLinkAbout1430 Stonehenge Dr - Applications/Gas - Log, Line, Pipe - 04/12/20122012-04-12 12:26 A CLEAN SWEEP LLC 9703527089 >> 970-224-6134
P ill
City off 281 N ICCoollegevAvep P.O. Box 580
�t Transportation
Collins 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 jKGas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing Cl Sewer Line ❑ Photo-voltalc
❑ Ventilation ❑ Water Heater C] Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application,
Application # ?Jk l.�.l � M 0
For fflce use only
Incomplete applications will not be accepted.
Date
3F1.I:o�
fob Site Address (required) Value of Construction (labor, materials, profit)
ICI D t�r�e hen L $ l➢Z r1 eel
Property Owner Name Address
City/State
Zip
Phone
YIC] 1 albv��-F` 1LA30S�Uneher �2. '�.C�
!N%!3
q -;(�� lU2
Applicant Name Address
CO/State
Zip
Phone
nCec (y,%A Q boi
r1qeq 6tee�,A c�
�033
q• 0.339-$3�5�
Contractor LIC # Address
City/State
Zip
Phone
�riciLQ
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by
report?.Mere ❑ Report
Sales taxnumber isrequired byall mntra 7 ia�
Are you paying with your trust account? ❑ Yes �lo
Is this a residential or commercial project? A Residential ❑ Commercial
If residential, Is It: >if 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? O Yes d No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestas assessment to submit with this application
Description of work
%ar—
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or (3ty of Ft Collins license 0
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: l�p'�cy� �� to � Signature �*' �t ��e� Date 'a', 01,