HomeMy WebLinkAbout4242 Table Mountain Pl - Applications/Furnace - 11/25/2014City of
Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
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
❑ 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 # a [!! I ir-),o1 Date
Fbr office use only
Job Site Address (required)
ValueofConstruction (labor, materials, profit) 20050. ut
)!i )- 1 4 �I
M 1y
J Y U n 1 �!
�Jl
1 1 Pt. L o li i 1210 C
01" 1'19 - 0 • `1
Property Owner Name
Address
City/State Zip
Phone
w'JLl)_'T.Sfie
PI. F�.coil,-, C0 S-vnc Gus-F=-X7,��
Applicant
Address
City/State Zip
Phone
�N'e
,. V� �•1_
PO `iJi
d���Vt U sSGS- 11—
9_7o-21 -56-171-
Contractyo+r
Address
City/State Zip
Phone
�JI Jnt p
((Oo D6
.oL [V�-
i70-4`f
Contractor City of Ft. Collig Sales Tax #
Are you paying taxes here or by report?
❑ Here aReport
sales tax number is required by all contractors.
Are you paying with your trust account?
❑ Yes PbNo
Is this a residential or commercial project? 0 Residential ❑ Commercial
If residential, is it: ED Single Family Detached ❑ 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 PNo Ifyes, you mayneed to contactHistaric Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
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:
Print Name: Signature to H - I