HomeMy WebLinkAbout5239 Country Squire Way - Applications/Mechanical - 06/10/2015Jun 101503:44p Hahn plumbing
970-493-5325 p.1
City of
Planningr Development &Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CD BD524
Phone 970-4:L&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
❑ Demorrtion (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Ug Gas Log
❑ Heating Unit ❑ lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line . ❑ Photo -voltaic
0 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 �150442r. Date S
For orifice use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
5
S_V
Pr erty Owner Name
Address
C&IState ZJp Phone
Applicant Name
Address
City/State Zip Phone
NdI
Contractor
Address
City/State Zip Phone
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Contractor City of Ft. Collins S
Tax # M P- / S
Are you paying taxes here or by report? ❑ Here l <Report
saresrax
Are you paying with your trust account? XYes ❑ No
l(Q2,7A
Is this a residential oKsluldfamily
merdal project? Residential ❑ Commercial
if residential, is it:ngle Family Detached 13Cando/townhome (single family attached) • . Q Duplex
(apartment) 0 Garage
If commercial, is it: ❑ Bank ❑ Bar Q Church f1 Hetel/Motel ❑ Medical office 13 Ofrlce ❑ Retail
❑ Restaurant 13 Other (explain)
Is this building 5o years of age or more? ❑ Yes ❑ No If yes, you mayneed to contactHistoricPresetvation
If this is for a demolition permit, what year was the building constructed?
ff pro,- to 197f, you wfii need an asbestos assessment to submit with this appiicabron.
work
flf lawn sprinider/backfiow preventer, must list licensed plumber. If first-time A/iti must list licensed electrician.
Subcontractors: List Me company name or[ayafPrCoffins ftenseif
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. r know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Nam
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