HomeMy WebLinkAbout930 Gilgalad Way - Applications/Water and or Sewer - 08/07/2015City O$ p1 Planning, Development & Transportation
F®r1}. Collins 1s Fort N. College Ave P.O. Box 580
�.- Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
4170?. a3
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 # b1,,506%Date 9/711.5
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
q so �-I C40 1 o' U' nD:ly'S
lco ,�52[0 O
Property Ownd Name J Address
City/State Zip
Phone
Lrxinc.�, KAA (75 S c.
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Applicant Name Address
City/State Zip
Phone
Ad �'. �e 737 m �e 8�' Itj2 TGl }Col V1 C Cn SZ
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Contractor kogV_k -yi CO PI Li nnlut'r �1 Address
City/State Zip
Phone
C
J. 10-S7° 73/J SLp'
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
*Here ❑ Report
sales tax number is required by all contractors.
Are you paying with your trust account?
❑ Yes X No
Is this a residential or commercial project? ❑ Residential jgcommercial
If residential, is it: p Single Family Detached ❑ Condo/townhome (single family attached)
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office
❑ Duplex
❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes q No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Yprior to 1975, you will need an asbestos assessment to submit with this application.
Description of work t&)rd-z�
*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:
Print Name: A20rj Signature
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Date '