HomeMy WebLinkAbout1636 Collindale Dr - Applications/Water Heater - 02/14/2012Feb 1512 09:19a Hahn Plumbing
9704935325 p.1
City OT
�F6rt Colons
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
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 ❑ Gas Log
❑ Heating Unit .❑ Lawn Sprinkler 0 Mobile Home replacement ❑ Reofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ,x 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.
�+pplication #_ 61 R G j yD
For orrice use only Date r L� — d5 . DQ
)ob Site Addresslrequired) Value of Construction (labor, materials, profit)
Pr p2rty Owner Name Address
City/State Zip Phone
14A .0
Applicant Name A r ss Clty/State Zip Phone
i I , ` - 4, r . �, r
Contractor
Address City/State Zip Phone 1L _ . 'l r7 1
Contractor City of Ft, Collins S s Tax * •
n'1 P- / 5 Are you paying taxes here or by report? ❑ Here I <Report
Sales tax number,& required byali contractors Are you paying withyour trust account? XYes ❑ No
l� 'q
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it; Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
I -Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel CI Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No Ifyes, youmayneedto contact HistoricPreservadon
If INS is for a demolition permit, what year was the building constructed?
Tf prior to r9751 you wi/l need an asbestos assassmant to submit with this application.
Descripticil cf work
*If lawn sprinkler/backrriow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of FtCcllinslicense 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�A''t •+ . ,/� Jia p l
signatur �� N� � � _ (� t /' Date � � >✓ L
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