HomeMy WebLinkAbout744 Langdale Dr - Applications/Water Heater - 12/11/2015DEC/18/2015/PRI 03:47 PM FAX No, P,002
City of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
\ art Collins Fort Collins, CO 80524
r Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
'r This application is to be used to apply for the following permits only (check all that apply), ❑ Air Conditioning
M Demolition (interior non-structural) ❑ Electicai Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit p Lawn Sprinkler 4 Mobile Home replacement Q Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation 9 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 # 15IS05;�¢b2(,, Date
For office use only
Sob Site Address ftg1u-ired) Value of Construction (labor, materials, profit)
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Property Owner ame Address City/State Zip Phone
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Applicant Name Address City/State Zip Phone
:)Qthe 41b EXIOUJ 4 &CP'VY - 6 Lt.
Contractor Address City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Ef Here ❑ Report
5ales taxnura er4 q �� byall mn"cilom Are you paying with your trust account? EfYes ❑ No
Is this a residential or commercial project? $ 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 (explairyyr}
Is this building 50 years of age or more? ❑ Yes �No If yes, you may need to contact H/storicPreservarlon
If this is for a demolition permit, what year was the building constructed?
Ifpr/or to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinlder/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft CollMs license ,#
Sectrican Plumb , 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; It
PrintName: 'sit Signature Date 1 j