HomeMy WebLinkAbout1612 Quail Hollow Dr - Applications/Gas - Log, Line, Pipe - 12/29/2015DEC-29-2015(TUE) 12;48 P.001/001
1 we r rn-i lis
Ci# Of Planning, Development & Transport;ation
FY 2131 N. College Avo P.O. Box Sea
�r� Collins Fort Collins, CO 80524
�•^- Phone 970-416.27g0 Fax 224-61341
OVER-THE-COUiVTER PERMITS ONLY
This application is to be used to apply for the following porni is only (checl(all that apply), AIIr Qondltl ring
Demolition (Interior non-slructurap Electrical Alteration (not service change) Gas Lighter r\ Gas Log
Heating Unit Lawn Sprinkler Mobile Home replacement Roofing Sewer Line Photo=voltaic-'
Vefact rer Water Heater Water Line WoodlPellel Stove (must be EPA certified, provide make, model and
manufacturer).
Cort,pfoto all oppficablo information on the application.
Application # 3j�J0 q 0-4a
For oMee nsc only
]ob Site Address m& ww)
incomplete applications will not be accepted,
Date__ t7,r-Z; 2015 .
Value of Construction (labor, materials, profit)
Property Owner Name
0-t('I.
Address
ALy/State
r Zip
Phond
N W�
,Si)zLL., ±
.)WIDW Utz 1-C./rc
Applicant Name
Address
Oty/state
Zip
-Phone
Contractor Address Llwstate Zip Phone
11Ui?`.S'C�rtt,1 �(c,F1�.aCt; SapPl.�' l4ra�, 121JcD:yIDG Or; �
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here Tlfeo
SrhsCArnumbeY'JSrrpnlr�yy,trydwAracox + Are you paying with your trust account? Yes
Is this a residential or commercial m ece
al
If residential, Is ik: S e Family metaeh � 20din to/townh me (dingle family attached) Duplex
Multifamily (apartment Garage
If commercial, Is It: Bank Bar Church Hotel/Motel Medleal'ofFice Office Retail
Restaurant Other (explain
IS this building So years of age or more? Yes o f y= you may need to cmiactHiSforiC PrCservStion If this Ufor a demolition permit, what year was the 1 ing constructed?
lrpr'!or to 19i5, M0 will nrod air aslx,tos y55=rment to subm/r with this applicalien,
of work
"IF lawn ,prtnkfer/backrlow preventer, must list licensed plumber. If fint'dme A/C, must Ilst HcenSed efearldan,
Subcontractors: bisrtlrreomp l7yyname urCr7yorRC1211insliCensea
FI*' n_ Pfer
t` kp�L---
I hereby acknowledge that I have read this application and State that the above Information Is complete and correcC. t agree to
comply with an requirements contained herein And city ordinances and state laws regukiting building construction. I know that a
permit is nolvalid until it has been paid and Issued. 6c'CL- yl -ev G W 25 Crvt -i'zrep Lace. �1
Applicant: Print Name: � Si r�ir err. Z"l t)�.t: 2®I