HomeMy WebLinkAbout2815 Outrigger Way - Applications/Water Heater - 08/28/2015Resend09-25-15;01:06PIJI; ;970-484-4448 w 3/ 10
City Of
F6N Collins
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 Un'itI ❑ Lawn Sprinkler El 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 Ibe accepted.
Application #4 n 1S6 76 16t.. Date 31, A
for o/Ilce use only
Job Site Address (Mgalred)
W
Value of Construction (labor, materials, profit)
P perty owner Name
Addr ss
City/State zip
Phone
Applicant Nam
ShP; -i'n
Address
/6► 5. LiN-'
City/State Zip
�_N. �c Lo Xa5ay
Phone
q70-q8�1-wqf
Contractor
Address
City/State ZIP
Phone
0
0 / 5. thV4 /,/V Foe, u yd4 y
JWy tlev l
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Mere .Report
Sales,.�nurnberisrequ/redhyallronCvcrors
Are you paying with your trust account?
'�I_Yes ❑ No
Is this a residential or c mmercial protect? residential ❑Commercial
If residential, is it: or
Family Detach d ❑ Condo/townhome (single family attached) ❑ Duplex
/❑ Multifamily (apartment) ❑ Garage
If commercial, is It: ❑ Hanle M Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 5o years of age or more? 0 Yes ❑ No Ifyes, you mayneedto contact HlstorlcpmserlaiYon
If this is for a demolition permit, what year was the building constructed?
Yprior to 1975, you will r/qd an asbestos assessment to submit with A9/s appl/catlon.
Description of work
*1° lawn sprinkler/backflow preventer, must list licensed plumber. If first-tlmc A/C, must Ilst licensed electrician.
Subcontractors: Llstthe mmpanynameorCItyofFtCollins lirense#
Electrician Plumbed
Mechanical Roofer
Other
I hereby acknowjedge 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: y /y/Y,, /
Print Name:��l�l 0 R I fGt7lo Signature lk1LA ate 44z