HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Applications/Water Heater - 01/19/2016From:
01/19/2016 15:43 #288 P.003
of
Flirt C4ttins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior noh-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation 6YWater 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 # �Q �(� U Date i - 1(-1
For office use only
lob Site Address (required)
Value of Construction (labor, materials, profit) l 1 9 1 2
Property Owner Name
Address City/State Zip Phone
St c
- �G s , C;-• �.. .
Applicant Name
Address City/State Zip Phone q"I n
-a-- n GC ls� - L.C,9-3
Contractor
Address City/State Zip Phone Ci-7G
P1 u
D.D1 �- Y 1 o Zino -t0D
Contractor City of Ft. Collins Sa Tax #
Are you paying taxes here or by report? ❑ Here ❑ Report
Sales taxrrumberisrequIrredbyall contraciors
L-1 i o-7 )
Are you paying with your trust account? gYes ❑ No
Is this a residential or commercial project? UrResidential ❑ Commercial
If residential, is it: ❑ Single Family Detached Condo/townhome (single family attached) ❑ Duplex
D Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar Ci Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes �No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work s ck - o �. � � e 1� (� O
'If lawn sprinkler/backgow preventer, must list licensed plumber. If first-time AX, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber 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: l
Print Name Signatur� cLs,_►�1Date