HomeMy WebLinkAbout1821 Rolling Gate Rd - Applications/Mechanical - 05/09/2012Fort Collins
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
,11 Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation 6 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 # 01 ao i of Date �� �- �� 02� • 85
For office use only
Job Site Addres (required) \\ Value of Construction (labor, materials, profit)
$
Property Owner Name
Address
City/St e Zip
Phone
�r f:
�t;���11,� �s
- 6137
-14
Applicant Name
Address
City/State Zip
Phone
Cont r ctor Lic #
Address
E
City/State
City/State Zip
cs�
Phone
C w
45
e
-lebo
Contractor City of Ft. Collins Sales Tax
#
Are you paying taxes here or by report?
12,341ere ❑ Report
Sales tax number is required by all contractors.
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? (Residential ❑ Commercial
If residential, is it: D47Single 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? ❑ Yes �CNo If yes, you may need to contactHistoric Preservation
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
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
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: 9
Print Name: 2C. Signature Date � 'I d-1.