HomeMy WebLinkAbout612 Dartmouth Cir - Applications/Water Heater - 01/12/2016Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-613=1
This application is to be ttsed to apply for the following permits only (check all that apply). El Air Conditioning
f i Don',.oiition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
1-l"ating U1_1iJV Lawn Sprinkler ❑ ivlobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
t—i Vani:ilatio+i r 13vater Heater El Water Line ElWood/Pellet Stove (must be EPA certified, provide make, modal and
n .-InUfactUret).
Connpiete all applicable information on the application. Incomplete applications will not
^be accepted.
Application it-b [ �() y t� Date
F-)r nfi9[e use only
Job Site Address 0-0t7i!i/ad) Value ,of Construction (labor, materials, profit)
Job Site Addrass 0-0t7ill-ad)Oi
I :1 ,_ NICE Owner N e � Address City/State Zip Phone
same, 11qq
Aul�lica;�llVame••a Address City/State Zip Phone
ur
--Conti actor-( Address City/State Zip Phone
Contractor CiLy of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here Report
,,;n„ l,er is racleni«iby all contractors.
Are you paying with your trust account? Er�i,Yes El No
[s tliis a residential or commercial project? esidential ❑ Commercial
resici��ntial is it: �ingle Family Detached ElCondo/townhome (single family attached) ElDupleX
rLl Multifamily (apartment) ❑ Garage
Ir commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is tltis L)UkEng 50 years of aga or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preservation
[i' tl is is for a tiarioli�ion parn-it, what year was the building constructed? -----
if c r i �r try 1.975, you �Vill need an asbestos assessment to submit with this application.
`Description�fw�kW
W�_ "�
"mil: lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Sui)colitractors: List the company na177e or G'ty of Ft Collins license T
Plumber __.- Mechanical_ Roofer __ Other _.
ac:IGtowlodgz, that I have read this application and state that the above information is complete and correct. I agree to
,.ui tpy with all requirerncnts contained herein and city ordinances and state laws regulating building construction. 1101O v that a
i,ermit is not valid until it has been paid and issued.
79
Applicant:
Pf int Name: ._ 2Y'Y" 9 v] JQ i Ff, hJ Signature Ad L�UI�- .__........