HomeMy WebLinkAbout5120 Stetson Creek Ct - Applications/Water Heater - 04/20/2012APR-25-2012 09:14 From:Allen Service
City of
rFrt Collins
970 484 444e To:92246134 Pa9e:7�12
Planning, Development &Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COONTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior nor -structural) Cl Electrical Alteration (not service change) ❑ Gas Lighter 13 Gas Log
❑ Heating Unit U Lawn Sprinkler CI Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation Water Heater ❑ Water Line ❑ Wood/Peliet Stove (must be EPA certified, provide make, model and
manufacturer),
Complete all applicable information on the application. incomplete applications will not be accepted.
Application #� B I 0 o� 350 Date
Far 071ce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
5ta6 Lj 61N agkC'+ Co osw Ia15.00
Property Owner NirT�e Address City Late Zip Phone
KusS
_ ox ; �au� 2 $0530
Applicant Name Address
City/State
zip
Phone
C//o��n'Itl►ractortC�� Address
Gty/State
Zip
Phone
11U.4d�Y' + lq�
_�
• l i'iVl ,
�05dty'
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here j13!!keport
Sates tax number is reuuired by al/ contractors Are you paying with your trust account? ) { � Yes ❑ No
15 this a residential or commercial project? xResldential ❑ Commercial
If residential, is it: 0 Single Family Deta ed )XCpndo/townhome (single family attached) - Duplex
❑ Multifamily (apartment) 0 Garage ,
It commercial, is it: I] Bank ❑ Bar ❑ Church ❑'Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ yes ❑ No !f yes, you may need to contac7 lsiMal draft
If this Is for a demolition permit, what year was thel building constructed? ances with a draft ho
if prior to 1975, you will nced art asbestas assessment to submit w/th [his application. Test prior to final ion Safety
Description of
�n
*If lawn sprinkler/barkFlow preventer, must list licensed plumber. it first-time A/G, must list licensed electrician,
Subcontractors: Li5tthe companynamear0tyofFtCullieslicense #
ElecVioan__. _ plumher 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: , b, r 11 6ri �
; Print Name_.__
Signatur