HomeMy WebLinkAbout621 Keenesburg Ct - Applications/Water Heater - 03/20/2015Resend03-30-15;08;050 ; ;970-484-4448 # 4/ 10
4,4 cY CII 281 N. College Ave P.O. Box 580
�(��" WFort Collins, 16 80524
��.._`..�.�'. Phone 970-416-2740 Fax 2246134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following perinits only (check all that apply), ❑ Air Conditioning
0 Demolition (interior non-structural) 0 Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Healing Unktj ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation Qk 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 * S 152 o-1 r 61 SOX73Date
Forofllce use only
Job site Ad ress rrequ/redJ
Value of Construction (labor, materials, profit)
s
5
,v0
Property OvTepyame Address
City/State Zip
Phone
r
g��70
Appllcan Nam �/` Address
i QM
City/State Zip
90
Phone
170. 9 gI
T77N .
'Si
ntractor Address
fi /0 r
Clty/State Zip
Am.
Phone '
Iffy y8 1
n r" i
Contractor City of Ft. Collins Sales Tax*
Are you paying taxes here or by report?
Here PRep❑rt
Sales a enumberIM,byall conkacium -
Are you paying with your trust account?
Yes ❑ No
Is this a residential or commercial project? $lResidentlal ❑ Commercial
If residential, Is it Single Family Detached ❑ Condo/tnwnhome (single famlly attached) Cl Duplex
Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank L] Bar ❑ Church Cl Hotel/Motel ❑ Medical office ❑ office ❑ petail
❑ Restaurant ❑ other (explain)
Is this building So years of age or more? ❑ Yes ❑ No Zfyes, YOU mayneed to contWHlstorleftservadon
If this is for a demolition permit, what year was the building constructed?
ifpnorto 1975, you will need an esbestosassessmentto submit with MlsapplImbron.
Description of work
*If lawn sprinkler/backflow preventer, must list 11censed plumber. If first-time A/C, must list licensed electrician.
subcontractors. List the comaanyname or 0ty of Ft Coll/ns license,#
Electrician Plumber. Mechanical Roofer Other
I hereby admowledge 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:S6_r; Cr-Hr-%P(�:
Print Name;
Date .3~961-15