HomeMy WebLinkAbout2312 Charolais Dr - Applications/Gas - Log, Line, Pipe - 10/23/2015Cit
F®ryt Collins
of
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 TS 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 #
For office use only
Date
Job Site Address (required)
ia'l-a
Value of Constfuction (labor, materials, profit)
05a.(t,
Property Owner Name Address
Jay fac Giel4pc2 Q C),�r-06''f
City/State Zip
, I� , ' � a d
Phone
Applicant Name ' Address
City/State Zip
Phone
McIrcip rC1rWO Si Il
. 'C61 1 05'
7o- 2 1 �.2coL
Contractor Address
City/State Zip
Phone
ZDSOl
q7 0 -', I' -J00 '-
Contractor City of Ft: ollins 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 ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: Single Family Detach! ❑ 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?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*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: 1 Signature Date
I