HomeMy WebLinkAbout1007 Mullein Dr - Applications/Reroof - 05/08/2012May. B. 2012 12:57PM
of
FOft COLtins
No. 6496 P. 1
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 appiyfor 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 ARoofing ❑ 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. Incomplete applications will not be accepted..
Application #
For office use only
Date S - 9>. i 2 3CDJ
]ob Site Address (required)
Value of Construction (labor, materials, profit)
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' v� . $S 12scx:�, .
Property Owner Name
Address City/State Zip
Phoneii34' I'1
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Applicant Name
Address City/State Zip
Phone
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Contractor
Address City/State ,Zip
Phone
CC. -
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
sales tax numberj:srequired byall mnbactw.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? EZ Residential ❑ Commercial
If residential, is it: 04 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 %No If yes, you may need to contact H/stodcPresetvat/on
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work ?gj21R.0 IrZ6+ .
*If lawn sprinkler/baddlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty of Ft Collins license #
Hecridan Plumber Mechanlcal Roofer r gOther
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.
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Applicant: C�
Print Name: e da.ICX �� " I(}�a rI t ire
Date 5J g' l Z •
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