HomeMy WebLinkAbout800 Grouse Cir - Applications/Furnace - 03/09/201504-08-15;09:40AM; ;970-484-4448 # 11/ 13
i .f Ly %++ 281 N. College Ave P.O. Box 580
Fort Q ,��j Port Collins, CO 80524
Phone 970-416-2740 Fax 2246134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply), 13 Air Conditioning
` 9 Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
?.Heating Unit 0 Lawn Sprinkler 13 Mobile Home replacement ClRoofing ❑ Sewer Line ❑ Photo -voltaic
Cl -Ventilation 0 Water Heater O Water Line ❑ Wood/Pallet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable Information on the applIcatlon. Incomplete applications will not be accepted.
Application # & 5o 23-T 2 • ' pate
Forolnce use only
Job Site Add ss (required)
Value of Construction (tabor, materials, profit)
61c
.DD
Property Owner Nam Address
City/State ZipO
1� Phone
90
0~
77ZIp
Applicant Nam Address
city/State Phoonne
ko 17a• S 8V/
ntractor • Address
e I( /of &JiAig
city/State Zip Phonb
We P& a ROOMY yry § 1
Contractor City of Ft. Collins Sales Tax #
Sa/estarn!7!7n��Obya/lconaadm.
Are you paying taxes here or by report? 17 Here report
Are you paying with your trust account? Yes ❑ NO
Is this a residential or commercial project? Residential 13 Commercial
If residential, Is it: Ingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamliy (apartment) ❑ Garage
IP commercial, is it: ❑ Bank ❑ Bar ❑ Church 0 Hotel/Motel ❑ Medical of ice ❑ pfflce ❑ Retall
❑ Restaurant ❑ Other (explain)
Is this building So years of age or more? Q Yes ❑ No !ryas, youmayneed to conbctHistorfck etmeon
If this Is for a demolition permit, what year was the building constructed?
lfprlorto I975, you tvillneed anasbestosassessmenttosubmltWi0r/sappl@at/on.
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: Ust the companyname orOlyofaCbll/nslicense #
Electrldan Plumber. Mechani®t__ . Roofer. Other
I hereby acknowledge that I have read this application and state that the above informatlon Is complete and correct I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building constructlon. I know that a
permit is not valid until it has been paid and issued.
Applicants
Print Name:S�urii('A 'Signature,
t•
Date ! — / 5-