HomeMy WebLinkAbout800 Grouse Cir - Applications/Water Heater - 03/09/201504-08-15;09;40AM; ;970-484-4448 # 12/ 13
'.oi #,y V' 281 N. College Ave P.O. Box 580
Flirt Colti s Fort Collins, CO 80524
Phone 970-426-2740 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
CI Demolition (interior non-structural) ❑ Electrical Alteratlon (not service change) 0 Gas Lighter ❑ Gas Log
!] Heating Unit [7 Lawn Sprinkler El 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 # 1;1502_ v i� I Sn '1(o Date `/5
, broff/ce use only
Job Site address (requ/
Value of Construction Qabor, materiats, profit)
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PropeLkowner Namq,
Address
Qty/State zip
Phone
1
Applicant Nam
. .0 J
Address
l . LJ Nail
City/State Zip
Phone
ntractor
Address
city/state Zip
Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
Are with trust
CJ Here deport
"es tax number�D ur�byaUmntraemrs
you paying your account?
79,Yes ❑ No
Is this a residential or commerdal project? )R Ikesidential ❑ Commercial
IF
resldentlair is it: �Qingie Family Detached ❑ Condo/townhame (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel 0 Medical office O Office ❑ Retail
❑ Restaurant ❑ Other (explain]
Is this building 50 years of age or more? U Yes O No If^ youmdyrreed iv conWCtHlstor/cPreservat/on
If this is for a demolition perinit, what year was the building constructed?
Irprlor to 1975, you cv!//ne�an asbesMs assessmentto subm/t cvi8h dr/sapp//cation.
Description of work
*If [awn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Llstthe company nameorOtyornCo//InsAcenm0
Ele&Adan 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 ordlnences and state laws regulating building construction. I know that a
permit is not valid until It has been paid and issued.
Applicants PrintName:L�r;7ir'i n'
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Dato -y�IS