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1 ` �v�./281 N. CoNege Ave. • Fort CoNlnsr Co 80824 • Phenet 970.416-V40
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BUILDING PERMIT APPLICATION
APPLICATION NUMBER_ 1✓ `�D k7 l APPLICATION DA
Job Site Address ur3'�_ Gfrc�� /i/6��G..
2
Unit #
(AN owner Information In required -his
not optlenai) Phone
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Lest name
First Name_
Cr% O*'s
Middle
Street Address Le
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City ��p%le1S
_ State_ILZip
CONTRemill INFO:
Company Name
Contractor Phone # 4-�-j 573 -30W
Lio Holder Name
City of Fort Collins Lioense #
Supervisor Cart #
Mailing Address/HZ
LEGAL INFO,
City zove4uve
Starts G, Ztpl53�
Subdivision/PUD Filing # Lot # Block # Lot Sq Ft
Total Building Sq Ft (notinduding bawftw)_ - Total Garage Sq Ft
Residential Sq Ft Comm'I Sq Ft— # of Stories Bldg Heigh` * Dwelling Units
1'^ Floor Sq Ft `_ � V Floor Sq Ft 9'" Floor Sq Ft Unfiished Bsmt Sq Ft
Finished Bemt Sq Ft # of Bedrooms # of Full Baths a/. Baths 'A Baths # of Fireplaces
Air Condtt9oning. YeflN Energy IlOb-' (Cirda appropriate choice) I.ComCheckEl 2. ResCheck w/AIr Sealing
3. ResCheok w/Blower Door11 4. Simulated Perforinance Ahernative❑ 6. Prescriptive w/Air Sealing11 6. Prescriptive w/ Blower Door
City of Fort Collins Stock Plan # List appropriate ocdon its
Water Tap Size Sewer Tap Size Metered: Yes []No[ Temp. Pedestal Yeso No [I,
Type of Neat D pas ❑Electric Electric Main Breaker Size (Residential only) ❑1So Amp or Less 200 Amp nother
Value of Construction //(including labor, material & profit) $
DesaiptionofWorlc:�5.6wrGI.C.9�R$o%tom �1.:..lti_e Q.�r rr. _ _1 J__ .i_ /``il
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Contact Name& Phone a ofJossITESUPERVISOR:
___
Electrical Mocha nioal Plumbing
Framer
Solar
Fireplace
_ Other
contained herreef�ne and
City o Fat that I have read this and asafe that tha above Information is aorreot and agree to comply with an requirements
City u>i Fat Colins citing state awa regulating building conmedon.
Applicant Signature Print Name . �C462�e• S Phone CIU-yd2-35Z2
Other
YeNow-Applicant Pink- VYVW mtormwater
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