HomeMy WebLinkAbout5025 Crest Rd - Applications/Water Heater - 01/26/2016Pianning, Development �c Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
This application is to be used to apply for the folloviing permits only (check all that apply). ElAir Conditioning
• Den.oiition (Interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
El Ventilation Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, modal and
iranufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application B1601360 Date
For ofFce use, only
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Value of CGons'truction labor, materials, profit)
306 si'i:'� �:ddd'� �/2r,�Uh'cc��� ( , � p� )
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r)r^perty OAer Name Address City/State Zip Phone i
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Applicant Name, Address City/State Zip Phone I
Contractor.-) Address City/State . Zip Phone
1Jy66�?Jy'�[/%�'�
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here Report
ta% i,umberisroquiredbya!/contractors Are you paying with your trust account? 'V,Yes ❑ No
Is this a residential or commercial project? esidential El 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. (explain)
Is this building 53 years of age or more? ❑ Yes ❑ No Ifyes, you mayneed to contact Historic Preservation
If this is for a demolition Permit, what year was the building constructed?
If prior to 1975, you wAl aced an asGestos assessment to submit with this application.
Description of work T)M. Q
If lawn spi inl<lel/backflow preventer, must ist licensed plumber. If first-time A/C, must list licensed electrician.
Sv bcontra ctors: L%st the company name or C%ty of Ft Col/ins license
L10ctricia11Plumber Mechanical Roofer, _ Other
r licrehy acknowledge that I have read this application and state that the above information is complete and correct. I agree to
comply with all requirements I contained herein and city ordinances and state laws regulating building constriction. I lti3ovv `that a
permit is not: valid until it I�a� been parr] and issued.
Applicant:
Print Name R i f`y" i' f'�'+3 Signature
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