HomeMy WebLinkAbout4152 Sumter Sq - Applications/Reroof - 08/18/2014planning. Development & Transportation
City Of 281 N. College Ave P.O. Box 580
Fort 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). 0 Air Conditioning
Cl Demolition (interior non-structural) 0 Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
0 Heating knit ❑ Lawn Sprinkler O Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
O Ventilation 0 Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application # (b Ia4-
For c7rlfce Lou orw
incomplete appiicans will not to accepted.
7 A
Date F—A -'Ay
Job Site Address ilrequvprd)
Value of Construction (labor, materials, prom)
Property Owner Name Address
Gty/state Zip
Phone
p
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Applicant Name Address
City/state Zip
Pion
Contractor Address
city/state Zip
Phone
Contractor City of Ft. Collins Sales Tax
Are you paying taxes here or by report? I3 Here O Report
-q9w Aw ruff&wijlr WLff qd by a# ca*ac1=
Are you paying with your gust a000unt? Cl Yes
10 No
Is this a residential or Commercial project? 1111 Residential O commercial
If residential, is It. 4& Single Family Detached O Condo/townhome (single family attached) O Duplex
❑ Multifamily (apahtmerit) O Garage
If commercial, is It: O Bank 10 Bar O Church O Hotel/Motel O Medical office O Office O Retail
❑ Restaurant: O Other (explain)
Is this building 50 years of age or more? ❑ Yes JgNo ffyes, you may need to contact Hlsitxic Pres+ervatlon
If this is for a demolition penmitt;, what year was the building constructed?,
llrpnar to 1975, you W# nerd an asbestos asSsrnent M wbm/t with dus application.
. ,*U
*If lawn sprinkler/baddlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subeontractwo: List the company name or Oty oft C 11m license 0
Electrician Plumber Medlank8l Roofer J ` other
I hereby acknowledge that I have read this application and state that the above infb oration is complete and Correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. II knew that a
permit is not valid until It has Neon paid and issued. r
Applicant: IA/..-1L
Print Name:, �/�� j Signature � Date / /