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CityofICOMMUNITY 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 RA W) 19 OF) APPLICATION DATE
Job Site Address y 331 j1h i I [ �£. tie Cr, 80Q, Unit #
PROPERTY
IIOWNER INFO: (All owner information is required — it is not optional) Phone #
Last name lit✓ t (t1q m S First Name ISO AA—/ k'� iS Middle
Street Address y3�Ty'YI i j' ( cv� f i Iz c . City l f 1 1v 9 State eo zip
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CONTRACTOR INFO: Company Name fj2V?-.t/JrAA_L C,•CJJ&l Ql�tc�idAContractor Phone # C� / 2
Lic Holder Name 1114411 e_ Cs= ipet G ► Q City of Fort Collins License #� Supervisor Cert #
Mailing Address � 7 ya-�-i✓✓J ✓ ��+/L�S ! �� City f?i2 I �� I t %�S State CO, Zip pS�
LEGAL INFO:
Subdivision/PUD
Filing # Lot # Block # Lot Sq Ft
CONSTRUCTION INFO: Total Building Sq Ft (not including basement) Total Garage Sq Ft
Residential Sq Ft Comm] Sq
1s' Floor Sq Ft
Finished Bsmt Sq Ft
2nd Floor Sq Ft
# of Stories Bldg Height # Dwelling Units
3'd Floor Sq Ft
Unfiished Bsmt Sq Ft
# of Bedrooms # of Full Baths % Baths '/2 Baths # of Fireplaces
Air Conditioning: Yes No Energy info: ( Circle appropriate choice ) 1. ComCheck 2. ResCheck w/Air Sealing
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:
List appropriate option #s
Water Tap Size Sewer Tap Size 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) $ )_ S ey, 00
Description of
a X Lif
Contact Name & Phone # of JOBSITE SUPERVISOR:
Subcontractor Info:
Electrical C� I� fa C Mechanical
Framereep' jAA,% ec".-la Roofing
Solar
Other
Concrete
Other
Z=0
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 Cgllins%rdin es and state laws regulating building construction. - (�
Applicant Signature ✓�d` Print Name gall L• OI gt"A- l Phone I � / Cf f
Distribution: White — Office Yellow — Applicant Pink — WWW/Stormwater
THIS APPLICATION EXPIRES 180 DAYS FROM APPLICATION DATE