HomeMy WebLinkAbout4210 Breakwater Ct - Applications/Gas - Log, Line, Pipe - 06/04/2012 (2)JUN-04-2012(MON) 10:29 P.001/001
City. of Planning, Development & Transportation
�. Fort Collins 281 N. College Ave P.O, box 580
For
�. Fort Collins, CO BO524
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 (chock all that apply). Air iticrling
Demolition (interlor non-structural) Electrical Alteration (not service change) Gas Lighter `Gas Log
Heating Unit . Lawn.Sprinkler Mobile Home replacement Roofing Sewer Line Photo -voltaic
Ventiiatlon Water"Heater Water Line Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all anolic lo Information on the application. Incomplete applications will not be aceeptod,
Application # 01 �d 65 Date�Q-
&r oNtee use only 96.00
lob Site Address (rkquirs~C) ^n Value gf fop ��O ( materials, profit)
qatI�`7�\t L`,C (___`III,..
ORNoperty 0 Name Address clty/ Zip Phone
%Applicant Na a Address City/State xlp Phone
Address
Contractor City of Ft Collins Sales Tax h r
Saks taxnumberlSrcQulrCd bYall ovrtraNuarx
awstate Zip
Are you paying taxes here or by report? Here Report
Are you paying with your trust account? Yes No
L this a residential or commercial project? es(den"a Commercial
If residential, Is IC oetae ndo/townhome (single family attached) Duplex
Muldramlly (apartment) Garage
if commercial, Is It Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this building 5o years of age or more? Yes No lfyes: you may head to cgntactH/sroric preservation If this Is for a demolition permit, what year was the building constructed?
If prior to l3y5, yotr wit/ need an asbestos assessment ea Submit with thfs applicatfan,
of
1plr Own sprinkler/backilow prevonter, must list licensed ptumber. tr first-time A/C, must Ilse licensed electrldan.
Subcontractors:/,lsrthe WnWrlynameor00,ofFtCallinslkerin. C
WewldanPlumber
- Mechanical.. Rooks Other.
I hereby acknowledge that I have read this application and state that the above inrormatlon Is complete and correct. I agree to
comply with all requirements contained herein and CILy ordinances and state laws regulating bullding construcdon. I know that a
Permit is not valid until It has been paid and Issued.
Applicant-
Print1 �n
Namam e. I SignaCu l,l
%��� [)ate �`