HomeMy WebLinkAbout404 Galaxy Way - Applications/Water Heater - 05/17/2012Jun 17 12.08:28a Francisco Manzano 87050616BG P.1
FCiof
ort 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) 0 Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Homo replacement ❑ Roofing ❑ 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.
�� So
Application # ��
For office use only
Incomplete applications will not be accepted.
DateL/7�/� �y
Job Site Address (required) Value of Construction (labor, materials, profit)
-tiogu�a $ Q e
Property Owner Name Address
City/State Zip
Phone
4'
Applicant Name Addres
City/State Zip
Phone
Contractor tic # Address
City/State Zip
Phone
iN6_L__M?.-62t1 ZUSMont
Pupi
Contractor City of R. Collins Sales Tax #
re yo paying taxes here or by report?
Mere ❑ Report
5aiestax numberisr 7ulmdbya11contmaors
Are you paying with your trust account?
D Yes GLNo
Is this a residential or commercial project? grAesidentlal ❑ Commercial
If residential, is it: Ea-Shljle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel CI Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you may need to contact Historic 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 Cty 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:
Print Name: 1 t&b�4tc w MAs47 k0t Signature
Date -5 ��