HomeMy WebLinkAbout229 Clover Ln - Applications/Water Heater - 06/01/2012Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box S80
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 ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation-1 Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable informationn an the application. Incomplete applications will not be accepted.
Application # B I a 0 33i Date kmk_"
for olfrce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
e \ \)'
Property Owner Name Address City/State Zip Phone
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Applicant Name Address Gty/State Zip Phone
Contractor Address City/State Zip Phone
Contractor City of FL Collins Sales Tax # Are you paying taxes here or by report? ❑ Here 0 Report
aksbrnambprisrequired by,711wntradors Are you paying with your trust account? AfYes 13 No
Is this a residential or commercial project? kQesidential ❑ Commercial
If residential; is it: "ngle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) O Garage
If commercial, is it: ❑ Bank O Bar ❑ Church 17 Hotel/Motel ❑ Medical office ❑ Office O Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No if yas, you may need to contact Hj&oonc Preservation
If this is for a demolition permit, what year was the building constructed?
0prior to 1975, you will need an asbestos assessment to submit with this application.
Description of
- it yawn spnnWer/Dacxnow, preventer, must list licensed plumber. If first-time AM, must list licensed electrician.
Subcontractors: List the companyname or GtyofR Collins license ,#
Electridan 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: V \j% xe Signature _t� �.._ Date 1
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