HomeMy WebLinkAbout1624 Scarborough Dr - Applications/Gas - Log, Line, Pipe - 12/17/2014City of
Port CoWns
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 #_ B i `i 10 q: "f Date _ 1 a -
For office use only
Job Site Address (required)
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Value of Construction (labor, materials, profit)
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3170%"'
Property Owner Name Address Gi /State
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Zip Phone
, fG.'i52 � 143-V-%
Applicant Name Address City/St&tJ
Zip Phone
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Contractor Address A- City/State
Zip Phone
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99033456
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?,tIt'hiere ❑, �Re�port
Sales tax number is required by all contractors.
Are you paying with your trust account? ❑ Yes oL-ryVO
Is this a residential or commercial project? AResidentiai ❑ 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 Ifyes, you may need to contact Historic 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.
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*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 2 eCe 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: V nco AA5,S�4� Print Name: ignature Date