HomeMy WebLinkAbout2004 Glenmoor Dr - Applications/Water Heater - 09/25/2014Resend10-03-14;01:52PM; ;970-484-4448 # 3/ 12
City. of
F.�art 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). 0 Air Conditioning
❑ Demolition Anterior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter C3 Gas Log
❑ Heating Unit ❑ Lawn Sprinkler O 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 pplicable information on the application. Incomplete applications/ will not be accepted.
Application # 1 A-10-11,fo Date
far office use only
Sob Site A (required)
Value of Construction (labor, materials, profit) do
of u I 5 `"
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Pro erty Owner N e Ad dr City to Zip
qa Psbolro SI
Phone
S
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Applicant Nam Address
She' 4W l L..W
City/State Zip
Phone
qra• 8 • 8y/
.
ntractor Address
O n erUi & /D 1 S. k ;Aj X
City/state Zip
uV2 P & a 905LI V
Phone
YYY_ 11491
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
Salrsraxnumber19twuobyall mnbaetas
Are you paying with your trust account?
.Yes C3 No
Is this a residential or commercial project? 12AResigpintial ❑ Commercial
If residential, is It: ❑ Single Family Detach d jLrondo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: O Bank a Bar ID Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant C3 Other (explain)
Is this building 50 years of age or more? ❑ Yes CI No Zfyes, you may need to contact H/stmicPreservatIon
If this is for a demolition permit, what year was the building constructed?
Yprtor to 1976, you w111 neAl an asbestus assessment to submit with this application.
Description of
*If lawn sprinkler/backfow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gly of Fe Colllgs 11cense 9
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 corstru0cin. I know that a
permit is not valid until it has been paid and issued.
Applicanti
Print Name: r i n Signature
jDate q_A57_jq