HomeMy WebLinkAbout1962 Massachusetts St - Applications/Furnace - 10/06/2015City of OCT 2 g 2015
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 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 # 81 '60 ��
For office use only
Sob Site Address (required)
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Applicant Name
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Contractor J
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Address
Address
Contractor City of R. Collins Sales Tax #
sales tax number is required by all contactors
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Address
Date i. o / b io / 15
Value of Construction (labor, materials, profit)
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City/State
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City/State
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City/State
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Zip 9 O Phone I l I"
Zip Phone rl 10
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Zip �305 3 "1 Phone c1'10
Are you paying taxes here or by report? Q Here ❑ Report
Are you paying with your trust account? ID Yes ❑ No
Is this a residential or commercial project? Q 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 5o years of age-nr-: '-"' '-' "^` n M- Ify_es, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructea r — If prior to 1975, you wi/l 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 # Other
Electridan_�— l
Plumber Mechanical Roofer
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. %know that a
permit is not valid until it has been paid and issued. /�
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Applicant: (II y,; D,i VJ;L 16 t-l= U. �" Signature /(�/l�•, � Date
Print Name: ; 1