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Cityof COMMUNITY DEVELOPMENT & NEIGHBORHOOD SERVICES
Collins 281 N. College Ave. • Fort Collins, CO 80522-0580 • Phone: 970-221-6760
www.fcgov.com/building
BUILDING PERMIT APPLICATION
APPLICATION NUMBER 'J 15y G APPLICATION DATE 1( ^ [ I — I-�
Job Site Address 'go Z 'PcIe irso b, J+ , SUS 2.X Unit #
PROPERTY OWNER INFO: (All owner information is required - it is not optional) Phone # 0 35 7 —0
70-6
Last name Ot S 0 cr V j First Name R� A / Middle / �,
Street Address goZ e-
Rk r'SD/ti �T City o r4 a(tt15 State W Zip ?&5 2
CONTRACTOR INFO: Company Name r Contractor Phone
Lic Holder Name City of Fort Collins License #
Mailing Address City State
LEGAL INFO:
Subdivision/PUD
Supervisor Cert #,
Zip
Filing # Lot # Block # Lot Sq Ft
CONSTRUCTION INFO: Total Building Sq Ft (not including basement) Total Garage Sq Ft
Residential Sq Ft Comm'I Sq Ft # of Stories
1 S' Floor Sq Ft
Finished Bsmt Sq Ft
Bldg Height # Dwelling Units
3'd Floor Sq Ft Unfiished Bsmt Sq Ft
0
# of Full Baths '/ Baths '/2 Baths # of Fireplaces
Air Conditioning: Yes No Energy info: ( Circle appropriate choice ) 1. ComCheck 2. ResCheck w/Air Sealing 1§0
3. ResCheck w/Blower Door 4. Simulated Performance Alternative 5. Prescriptive w/Air Sealing 6. Prescriptive w/ Blower Door
City of Fort Collins Stock Plan #
UTILITIES INFO:
2nd Floor Sq Ft
# of Bedrooms
Water Tap Size Sewer Tap Size
List appropriate option #s
Metered: Yes or No Temp. Pedestal Yes or No
Type of Heat: ❑ Gas ❑ Electric Electric Main Breaker Size (Residential
only) ❑ 150 Amp or Less ❑ 200 Amp ❑ Other
Value of Construction (including labor, material & profit) $ 74-
Description of Work: aPi1 L��y���— �zz �-�� w%2ef
Contact Name & Phone # of JOBSITE SUPERVISOR:
Subcontractor Info:
Electrical
Framer
Solar
Roofing
Other
Mechanical
Concrete
Other
Plumbing
Fireplace
Other
Applicant: I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all requirements
contained herein and City of Fort Collins ordinances and state laws regulating building construction.`
Applicant Signature(n•�,C�` Ci►�� Print Name 1 �onpntl�[OA. C:(SaA1 Phone (� a(.1'j 37
Distribution: White - Office Yellow - Applicant Pink - WWW/Stormwater
THIS APPLICATION EXPIRES 180 DAYS FROM APPLICATION DATE