HomeMy WebLinkAbout1600 Burlington Ct - Applications/Gas - Log, Line, Pipe - 09/15/20145EP-16-2014(TUE) 12:35 P.001/001
City of Planning, Development & Transportation
281 N. College Ave P.O. Box $80
Fort
Collins Fort Collins, CO 8OS24
�. 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). _ ing
Demolition (interior non•structural) Electrical Alteration (not service change) Gas Lighler Gas Log
Heating Unit Lawn Sprinkler Mobile Home replacement Roofing Sewer Line Pho
Ventilation Water Heater Water Line W0001*011e1. Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all appllcablo Information on the application. incomplete applications will not be accepted.
Application #— 0q Date I'S SgPT- i
For aVl'!cr vsr any
Job site Address (regrnrrd) Value of Con traction (labor, materials, pront)
]raw Nclmn Qum IR35(03 -
Property Owner Name Address City/state Zip phone
tn-AyA tIDW BUAlAhJ6170 ► CT pCc Lo 8C`r5 Z22."
Applicant Name Address aty/State ZIP Phone
Contractor Address City/State ZIP Phone
IM&*Tet2pl �l¢ pClr'SUPpI� (4b�jt2tJt ,iArCpiZ F-L�GD PJQ:52� 49�.�fa,
Conbactor Gly of FL Collins Sales Tax >r Are you paying taxes here ar by report? Here 1ram
SaAecraxnuzpxlsrr±qu6rdbyaDarcradorA I , : Are you paying with your trust a=unt7 Yes
is this a resitentlal or co r Pro1� 'ds
euaiCommercialIf residential, Is it: QMle Fainity Detached) tr/Cownhome (single family attached) Duplex
Multl m y (apartment) Garage
If commerdal, is it: flank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this building So years of age or more? Yes No /f
If this is for a demolition Cress lruu rnayneect act Misnxic Prercrvaperr
!fP*r to t9yf you wrfl �rrcd an asbestos a ra Wssesamenr to sul brrnConstructed?
Towl K a pplh2aan.
of work o
'ir lawn sprinidor/badcnow preventer, must list Ilcensed plumber. If first-dma A/C, must list licensed eieRrldan.
subcontractors: 4jRthr r:ompvny Me orCTty o/Ft Cotft #cease o
klearldan MachnnlCal Roorer�_
� nereoy aatnowledge that I have read this appNcadon and state that the above Informatlan Is Complete and Correct. t agree to
Comply with 611 rcqulrements contained hereln and rMy ordinances and state laws regulating building construction. I know that a
Permit Is notvaltd until It has been paid and Issued. 0 eqtVWV a W esio-n-Aeep lace . U\V-�
Applicant:
print Nome:
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