HomeMy WebLinkAbout3724 Bromley Dr - Applications/Furnace - 04/30/2015Resend04-30-15;03:30PM;
;970-484-4448 # 2/ 5
City f Planning, Development & Transportation
-- Y o281 N. College Ave P.O. Box 580
Flirt Collins Fort Collins, CO 80524
Phone 970-416-2740 Fax 22+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 ElMobile Home replacement El 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 # �_5 C)� 1 �(P Date 7-Jo 16
For office use only
Job Site Addre s (requlred)
Value of Construction (labor, materials, proto-
R.1file)
Owner Name Address City/State Zip
P;M-4AZDA
Phone
If — 7374f
Applicant Nam Address
&h ri i fl ID ► S. 1_itjK
city/state Zip
1-,►V. re e-o y05Aq
Phone
q-(0-y8k- ySKI
Contractor Address
City/State Zip
Phone
o i S.1.itie
4N. d, o 9d5ay
*/Y� y�y�
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
Sales Wxnumber Isrequiredbyall contractors,
Are you paying with your trust account?
'.Yes ❑ No
Is this a residential or commercial project? )Z Residential ❑ Commercial
If residential, Is it: RQingie Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
eb 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 ❑ No Ifyes, you may need to contaaHlstorlcPreservation
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 wo"his application.
Description of
*If lawn sprinkler/backFlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician,
Su bcontractors; Ust the company name or C/ty of Fr 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 J(-t �RIrffiJSignature1001(Lmll."
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