HomeMy WebLinkAbout5220 Boardwalk Dr - Applications/Water Heater - 05/07/2015Resend05-08-15;09:46AM; ;970-484-4448 # 8/ 10
F%-4 &'Y y, 281 IV. college Ave P.o. Box 58o
t Colts s 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 Altbration (not service change) ❑ Gas lighter ❑ Gas Log
❑ Heating Unit`/❑ lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation [AWater 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 # 22160,soylDate
ForoN&* use only
ess (required)
Job Site AXar&wakk
Value of Construction (labor, materials, profit)
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5" aoy6,00
perty owner Nam
Address
city/State Zip Phone
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a0032-
Applicant Nam
rr i1'fJ lot
Address
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city/State Zip Phone
g05Aq q70• g • 419,1/
address
ntracto&3du
n /e I & J
Gty/State Zip Phone
. P& LSD 9O6o4'/ Imp w l
Contractor City of R. Collins Sales Tax #
sales rarnL1mbdFzYO I �byarrmntrace0r .
Are you paying taxes here or by report? D Here PReport
Are you paying with your trust account?*Yes ❑ No
is this a residential or commercial project? i Res! ential ❑ Commercial
If residential, is it: ❑ Single Family Detach¢d — Condo/tnwnhome (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 SO years of age or more? ClYes 13 NO !t'yes, youmayneed to contact H1sWjfcPn servatlon
If this Is for a demolition permit, what year was the building constructed?
Ypnior to 1975, you w1/1 need an asbaMxv assessment submit rv164 &sappl/etlon.
Description of
*If lawn sprinkler/baWow preventer, must list licensed plumber. If first time A/C, must list licensed electrician.
subcontractors: Ustche mmpanyname orOYyofFtColl1ns11renx 0
Electrician Plumber Medwnical Roofer. other
I hereby acknowledge that I have read this oppilcation 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: �5. -7
Print Name:SAerrltA Signature Date
A.