HomeMy WebLinkAbout2217 Loyola Ave - Applications/Water Heater - 09/24/2015Resend10-20-15;04:17P,M; ;970-484-4448 # 12/ 12
t-orx %,bumb Fort Collins, CO 80524
Phone 970-41&2740 Fax 224-5134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following perinits only (check all that apply). 0 Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) I] Gas Lighter 13 Gas Log
0 Heating Unit 0 Lawn Sprinkler 0 Mobile Home replacement El Roofing ❑ Sewer Line ❑ Photo -voltaic
O Ventilation Water Heater 13 Water Line 13 Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer)
Complete all hplillcable information on the application. Incomplete applications will not he accepted.
Application # B I5b_11.5` Date 9- /
forofflce use on/y
gob Site Address fraqulred)
Value of Construction (labor, materials, profit)
as l!
Pr perty Owne ame Address
Gty/State Zip
/ Phone
Applicant Nam Address
' l �{i'A1 1 Q A I
city/state Zip
905'
Phone
q7'4. 8• �b l
rr .
Address
ntractoSery_LaL
Allen /D cS• i
City/State Zip
. PL & $O6�y
phone
1/Yy q 1
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
Are
Here jrteport
p
Sales tsrnumberi�ZquObya11con&actPm
you paying with your trust account?
Yes No
Is this a residential or commercial project? esldentlal M Commercial
If residential, is It: Angle Family Deta d ❑ Condo/townhome (single family attached) ❑ Duplex
0 Multifamily (aparbnent) 17 Garage
If commercial, is it: ❑ Bank 0 Bar 13 Church Ci Hotel/Matel ❑ Medical office LJ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building so years of age or more? t7 Yes ❑ NO ffyes, you n7ayneed to contact HistoffeT7j rvaGan
If this Is for a demolition perinit, what year was the building constructed?
Ifpriorto 1975, you Wllneed an asbestos assessment to submitWlth th/sappl/mtlon.
Description of work
*if lawn sprinkler/backflow preventeq must list licensed plumber. If flrst•dme A/C, must list licensed etecWclan.
Subcontractors: Ust the company name orOtyofRColpns/kpnse #
Ele triclan _ _ Plumber Meehanleal Roarer. 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*S A�p Print Name: I ii Signature
jDate - OI 7 /50