HomeMy WebLinkAbout213 Buckingham St - Applications/Furnace - 11/14/2014From
11/14/2014 09:05 0427 P.001/001
Fort of
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). 0 Air Conditioning
❑ Demolition (interior non-structural) 0 Electrical Alteration (not service change) 0 Gas Lighter ❑ Gas Log
StHeating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing 0 Sewer Line 0 Photo -voltaic
❑ Ventilation 0 Water Heater 0 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 #_Z(L� 1 ZZ L-I� Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit
av;'SaNsev gs r tea
Property Owner Name Address City/State
Qn Zip Phone
Applicant Name ���\A` I U at �C
Address City/State Zip Phone
Contractor Address
i % ` r %% n City/State Zip Phone
Contractor City of Ft. Collins Sales Tax # t
Are you paying taxes here or by report? NrHere ,Report
Syles tax number & required by all contractors. Are you paying with your trust account? KYes Q No
Is this a residential OrPmultifamily
commercial project? O` esidential O Commercial
If residential; is it: Ingle Family Detached ❑ Condo/townhome (single family attached) 11 Duplex
(apartment) ❑ Garage
If commercial, is it: 0 Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
O Restaurant ❑ Other (explain)
Is this building SO years of age or more? oyes ONO If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
rfprior to 1975, YOU wlll need an asbestos assessment to submit with this appllcabon.
Description of
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time AIC, must list licensed electrician.
Subcontractors: list the company name or City of Ft Collins license #
Electrician Plumber
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: � {� \tu& Gm& Signature
+�� Date �