HomeMy WebLinkAbout2821 Des Moines Dr - Applications/Reroof - 09/10/2014From: SCOTT EVANS Fax: (888) 503-7201 To: +19702246134 Fax: +19702246134 Page 4 of 7 08130I2014 11:24
.rry P3I �oafi€ oment & Transportatlon
or 1
V.U. oux aov
FrtColons Fort Collins, CO 80524
o
�"""�r �r�-•� , ` 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 CI Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer). ^ lA
Complete all applicable information on the application. Incomplete applications will not b ccepted.
PP
A lication # �]`� Date -1
For office use only
Job Site Address Nqulred)
Value of Construction (labor, materials, profit)
Z- Z f ; v_-
Aie,
eI-Y&,3, 2 S
Property Owner Name
Address
City/State Zip Phone
6A/?-e,1,'11441 ti
o fii`9 3�Z '��rf /x 77 l W!- 29'
Applicant Name
Address
City/State Zip Phone
Contractor
Address
City/State Zip Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? Plere ❑ Report
Sales tar number isrequlredbyaUcontractors
Are you paying with your trust account? ❑ Yes allo
Is this'a residential or c mmeraal project? Mesidential ❑ Commercial
If residential, is it: Single 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? i7 Yes ❑ No If yes, you mayneed to contactHistoric Preservation
If this is for a demolition permit, what year was the building constructed? Z 0'> Z
!f phor to 1975, you will need an asbestos assessment to submit with this application.
Description of work
LAVA
*If lawn sprinkler/baddiow preventer, must Ilst licensed plumber. If first-time A/C, must Ilst licensed electrician.
Subcontractors: List the company name or Oty of Ft CDAIns Jkense #
Electrician Plumber Mechanlcal Roofer `1 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: Cv/ J W Signature Print Name: ., ,
Date