HomeMy WebLinkAbout2619 Leisure Dr - Applications/Furnace - 12/02/2014hesena'I'I-V4-14;iu;'14AM; ;!J/V-464-444b . 7F 10/ 2u
Fort of
Planning, Development &Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 22+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
❑pemolition onterlor non-structural) IJ Electrical Alteration (not service change) ❑ Gas Lighter 17 Gas Log
/{eating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line CIPhoto-voltalc
D Ventilation ❑ Water Heater O Water Line O 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 # 014 j a:�6A g Date � r' • a
For orTlce ize only
Job $tte Address(rngalmd)
Value of Construction (labor, materials, profit)
er Name Address
City/State Zip
Tf`mrd
5 an JL IV �Phone
Applicant Nam Address
City/State Zip Phone
6shg•N . �. U
/�
3�y o 7 �:•
Contractor Address
City/State Zip Phone
i D Am
Am. r& GAD $oho? YY - 9 /
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? _ q Here Pkeport
sales tax number aemrs;
Are you paying with your trust account?1;&,Yes ❑ No
Ymal/Affldobyaffefin
J
Is this a residential or commercial project? 1d ntlal ❑ Commercial
If residential, Is it: ' ❑ Single Family Detached ondo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) Cl Garage
If commercial, Is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑Yes ❑ No Ifyes, you mayneed to contad His O&Preserm on
If this is for a demolition permit, what year was the building constructed?
ffprior to i97S, you W11 need an asbestos assessment M submlt w1t h dh/s appl/mb'on.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Ust bhe c»mpany name or 01y ofRGbl//ns l/cerm 0
Eledridan 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. X know that a
permit is not valid until It has been paid and Issued.
Applicants�•y(^�y(�'• ! 1 — Print Name: 11 7 i n SignatureDate d -