HomeMy WebLinkAbout4265 Southshore Ct - Applications/Reroof - 02/11/2015City of Planning, Development & Transportation
Fy} 281 N. College Ave P.O. Box 580 \
orrl Cottins Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY �U
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ 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 applicable information on the application. Incomplete applications will not be accepted.
Application # R ��� d6 0
For oh%e use only
Date - z-N 5-
Job Site Address (r uired)
Value of Construction (labor, materials, profit)
C Zi� L°
ibco
gVd — 4Z 6wo . cm�o
Property Owner Name
Address
City/State Zip
Phone
Ja &A 5
Smu
e ggs
- ts>
Applicant Name
Address
City/State Zip
Phone
[
1m -S e
7z0 - 3 -o a
Contractor
Address
City/State Zip
Phone
J64rS '
'%- /
( ) (I , e , , .y
20 L 3e�
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ere ❑ Report
sales tax number is required by all contractors,
Are you paying with your trust account.
1
❑ Yes ❑ No
Is this a residential or c mmercial project? Residential ❑ Commercial
If residential, is it: Single Family Deta ed ❑ Condo/townhome (single family attached) ❑ Duplex
�
// ❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes No Ifyes, you may need to contactfiistoric Preservation
If this is for a demolition permit, what year was a building constructed?
Ifprior to 1975, you will need an asbestos assessment to submit with this application.
— v -
*If lawn sprinkler/backflow preventer, must list licensed plumber. Ifirst-time A/C, must list licensed el ctri ion.
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:/��(f '�— -- Print Nam t 4 • Signat Date