HomeMy WebLinkAbout1120 Nassau Way - Applications/Water Heater - 07/12/2012JUL-16-2012 oe:21 From:Rllen Service
City of
Fort Collins
970 484 4448 To:92246134 Paee:7/12
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). El Air Conditioning
❑ Demolition (interior non-structural) O Electrical Alteration (not service change) 0 Gas Lighter U Gas Log
❑ Heating Un' ❑ Lawn Sprinkler Q Mobile Home replacement O Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation Nater Heater ❑ Water Line ❑ Wood(Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
complete all pplicable information on the application. Incomplete applications will not be accepted.
Application # Iy (� Date %� o2' OO
For office use only
Job Site Address (rentdred)
Property ner Name
f�
Applicant Nam
,S (n i t!114fh k
Contractor
Address
Address
Value of CNl-Construction (labor, materials, profit))
GCS 5A"J - ''an Vr&
City/State
City/State
cult~ h S/ co
City/State
Zo
Zip
Zip
Phone
55(-
Phone
)10. 4 g-P. 494t
r 41hw y:
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here
Sales tax number is regorad by a0 tW6Wt0f1. Are you paying with your trust account? )A Yes
Phone
'gy-
X Report
❑ No
Is this a residential or iqqmmercial project? AAesldentlal ❑ Commercial
If residential, Is it: ngle Family DetachW 13 Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage '
If commercial, is it: 0 Bank ❑ Bar 0 Church ❑ Hotel/Motel O Medical office - 0 Office C] Retail
Q Restaurant ❑ Other (ex Jain)
Is this building.50 years of age or more? O Yes ,��qo If yes, you rnayneed to contactHisfnric Preservadon
If this is for a demolition permlt, what year was the llding constructed?
11 prior to 1975, you wilt need an asbestos assessment to submit wilt this application.
Description of work
*If lawn sprinklerjbaektlow preventer, mt4t list licensed plumber. if first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Collins license 0
elewidan Plumber I Mechanical Roarer Other
I hereby acknowledge that I have read this application and state that the above Information is complete and correct. 1 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: rl 66Slgnatur - Date -