HomeMy WebLinkAbout3924 Benthaven St - Applications/Furnace - 03/03/2015Cit
of
F®ryt Collins
OVER-THE-COUNTER
Plan ing, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
This application is to be used to apply for the following permits
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not sen
IA Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove
manufacturer).
Complete all applicable information on the application. Incompl,
Application # ` Date
For office use only
ITS ONLY
y (check all that apply). OAir Conditioning
change) ❑ Gas Lighter ❑ Gas Log
rofing ❑ Sewer Line ❑ Photo -voltaic
ust be EPA certified, provide make, model and
applications will not be accepted.
3131 I16
Job Site Address (required)
Value
of Construction (labor, materials, profit)
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Property Owner Name
Address
City/Sate
Zip b 0 5ZIv Phone(9 i D
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Applicant Name
CIn �vn"ltir
Address
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City/S
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ate
/� Zip Phone 9 7 o
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Contractor J
Address
City/S
ate
Zip 2 u5 3� Phone 110
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Contractor City of Ft. Collins Sales Tax #
Are you payinc
taxes here or by report? Q Here ❑ Report
sales tax number is required by all contractors
53 ?.Io
Are you payin
with your trust account? L] Yes ❑ No
Is this a residential or commercial project? PResidential ❑ Commer
If residential, is it: ® Single Family Detached ❑ Condo/townhome (:
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Me
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No Ifyes, yourr,
If this is for a demolition permit, what year was the building constructer
Ifpnor to 1975, you w111 need an asbestos assessment to submit with this
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time
Subcontractors: List the company name or City of Ft Col/ins license #
Electrician Plumber Mechanical
family attached) ❑ Duplex
office ❑ Office ❑ Retail
need to contact Historic Preservation
lV
must list licensed electrician.
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 law regulating building construction. I know that a
permit is not valid until it has been paid and issued.
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Applicant: C I
Print Name: I N Dy VJ 2 I U N
Signature Date