HomeMy WebLinkAbout926 Akin Ave - Applications/Gas - Log, Line, Pipe - 08/22/2012City of
-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) ❑ Gas Lighter ❑ 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).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # &0-1050W Date P
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
f%Z (e $ (000, 01)
Property Owner Name IAddress
City/State Zip
Phone
To S� u ey qz*Ad:;,l
/=c Co A 2
�7 0 8-23
Applicant Name
Address
City/State Zip
Phone
Contractor Lic #
Address
City/State Zip
Phone
Pk 10
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here E-R-eport
sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes 2_ VI'o
Is this a residential or �cco�mm ercial project? Residential ❑ Commercial
If residential, is it: 13Single 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? ❑ 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. A
Description of work T S�i� �� 1;*0e 6eo%lQ 6&s roe Cacgx: r
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber v 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: Signature Date 6 ZZ "/