HomeMy WebLinkAbout4114 Rolling Gate Rd - Applications/Air Conditioner - 07/22/2015City of o Planning, Development & Transportation
281 N. College Ave P.O. Box 580
F®rt C®Llf ns 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
I5-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). ;L% 31
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # PJ 1 S 1)6c) Date
For office use only
lob Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State Zip If Phone 170
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Applicant Name
Address
City/State ip Phone
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Contractor
Address
City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? .0 Here ❑ Report
sales tax number is required by all contractors.
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? 15 Residential ❑ Commercial
If residential, is it: ;S 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 SO years of age or more? ❑ Yes B No If yes, 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.
Descri ption_ of
C.
*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: nn�AA& �
Print Name: MA 44' �r ywq rr Signature 10- _ Date p'