HomeMy WebLinkAbout3112 Sam Houston Cir - Applications/Water Heater - 01/07/2015From:
01/07/2015 12:17 0109 P.002/002
of
Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 2246134
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 KWater 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 # B 15C 11 H
For office use only
Date
lob Site Address (Aquired I
Value of Construction (labor, materials, profiitt)
0
OD
P operty Owner ame
Address
City/Stag Zip Phone
�� M r, �, i 1 S"' i� _6361
Applicant a
Address
City/State Zip Phone
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1.
Cl
Contractor
Address
City/State Zip Phone
iS
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Contractor City of Ft. Coll ns Sales Tax #
Areiyou paying taxes here or by report? Here ❑ Report
sales tarnumber Brequlredbyall contractors.
L4 1 N-1 (
Are you paying with your trust account? Yes ❑ No
Is this a residential or commercial project? !Residential ❑ Commercial
If residential, is it: 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 ❑ No If yes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
lfprior to 1975, you will need an asbestos assessment to submit with thts application.
Description of work
*If lawn sprinkler/backtlow 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 Mp - 3.0 1 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
Date