HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Applications/Water Heater - 06/24/2015 (2)Planning, Development & Transportation
City of 281 N. College Ave P.O. Box 580
FortCollins Fort Collins, CO 80524
'�> A Phone gins, CO 8052 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 #
aU 160 �51_I I `4Date
For office use only
Job Site Address (required)
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Pro rty Owner Naa--e '`
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Applicant Name
CI n A, Vv in c`,.`:r 4-0,59,
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Contractor J
Value of Construction (labor, materials, profit)
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Addr
City/State
Zip 3 O 5 Z5 Phone �j O
5LC
CAPS C-
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Address
City/State
U Zip Phone 410
Address
City/State
Zip ` O5 31 Phone
Contractor City of Ft. Collins Sales Tax #
sales tax number is required by all contractors.
53 Zio
Are you paying taxes here or by report? Q Here ❑ Report
Are you paying with your trust account? M 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 may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you will need an asbestos assessment to submit with this application.
Description of
*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 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: C i tit D11 VJ (L I U H Signature l /(%t :I- \'I �1 1�! �.. _ Date
Print Name: ; I 1