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HomeMy WebLinkAbout1718 Palm Dr - Applications/Water Heater - 12/02/2014From 12/02/2014 08:51 4l099 P.002/002 City, of Planning, Development & Transportation 281 N. College Ave P.O. Box 580 F6rt Collins 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). ❑ Air Conditioning ❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log U Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic ❑ ventilation Vwater 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 # 112—] i Date For office use ony Job Site Address (required) Value of Construction (labor, materials, profit) / /S, lv-�.3 l ,Cv/l'H5 b'2 �/ q /D, ©� Pro Owner Name Address City/State Zip Phone J,e65tccf (.�� /7/? �1r,}'�rI�L`'� W(odic 6) &4=/ Applicant Name / Address�y/State Phone LY-ian�G q� k ` t! o Q J-r. St*� - //�� c�ZiP r-U a `p� 97oG1s9'—Lv93 Contractor Address city/state Zip Phone ( �1v., ��Lrrvl ji"F> %H a ��y o�Ot /�tGr `Jl j� I�JyrFisYa/ C J t f!v 3'I rl �. �7JG , i,�Jg3 Contractor City of Fftollins Sale'; Tax Sales tax number is required by ad contractors y/dnl Are you paying taxes here or by report? ❑ Here ❑ Report Are you paying with your trust account? CPYes ❑ No Is this a residential orco L'9 rcial project? 1;sidential ❑ Commercial If residential, is it: Mingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex ❑ Multifamily (apartment) ❑ Garage If commercial, is it: ❑ Bank 0 Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail ❑ Restaurant ❑ Other (explain), -- Is this building 50 years of age or more? ❑ Yes BIV-0 If yes, you may need to contact Histonc preservation If this is for a demolition permit, what year was the building constructed? If pnor to 1975, you will need an asbestos assessment to submit with this application. Description of work ooa-lrr` *If lawn sprinkler/backFlow preventer, must list licensed plumber. If first-time A/C, must list licen,;M Plcvrr rca� SUboontractors: List the company name or o'ty of Ft Collins license Electrician Plumber irl r -S aZ y 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: tt Print Name:_��i lri h tii ,,lie. r-dWL { signature D !x 'i /;� : -/ y Date