HomeMy WebLinkAbout632 Agate Ct - Applications/Gas - Log, Line, Pipe - 01/06/2016City of p n Planning, ,Development &'Transpo.�- 'aticn
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0f- r , !l 281 N. College Ave P.O. Box 560 E� �a Fort Collins, CO 60524
Phone 970-416-2740 Fax 224-6134
This application is to be used to apply for the following permits only (check all that apply). Air G.p. d-i loping
Demolition (interior non-structural) Electrical Alteration (not service change) Gas Lighter •; Log Heating Unit Lavin Sprinkler Mobile Home replacement Roofing Sewer Line Photo=vo alc r Ventilation Water Heater Water Line Wood/Pellet Stove (imUst be EPA certified, provide make, model and
manufacturer).
Complete all applicable) information on the application. Incomplete applications will not be accepted,
Application # -N boob-4 Date ao J-AN (
For ofce use only
Job Site Address (required) Value of Construction (labor, materials, profit)
632 AC-z.4Tu_ c-r
Property Owner Name Address City/State Zip Phone
`WWE 221ZE=,
Applicant Name Address
City/State Zip Phone
Contractor Address City/State � Zip Phone
vCr�i�rz i t7 L/�C„ ene t.} I-rc1-C `=i-•Pt' l.T.j' l `-I (Carl 4-lv Cl—y ��7i: P� �- c.
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here e ort
Sa!estax number isrequirc-dbya!1conrractors. Are you paying with your trust account? Yes No
Is this a residential or commercial project? eiLdential Commercial
If residential, is it: _Sipgl�Family Detached Condo/townhome (single family attached) Duplex
(4LJ tb'Faf milt' apa men
Garage
if commercial, is it: Bank Bar Church Hotel/Motel Medical office Office Retail
Restaurant Other (explain)
Is this building So years of age or rnore? Yes c(2E7:�7yes, You mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
lfprior to 1975, you roil/ need an asbestos assessment to suGmit faith t/ris application.
of work N l N 5 T ,d Ut__
*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
EIecf n Plum
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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 notvalid until it has been paid and issued.
Applicant:
Print Name:=�1t�:L_X_ Signatur
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