HomeMy WebLinkAbout5638 Evening Primrose Ln - Applications/Gas - Log, Line, Pipe - 04/25/2016Planning, Development u Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conclitioninc 1
• Den;oiition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ 1-leat'ing Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, mod l and
manufacturer).
: ,omplote all applicabla information on the application. Incomplete applications will not be accepted.
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Application �# I�Ac�a� Date
For office use only
Sob Site Address (require
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'Jalue of Construction (labor, materials, profit)
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Property Owner me Address City/State Zip
Phone
Applicant Name Address
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City/State Zip
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Phone
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Contractor. Address
City/State Zip
Phone
6- 41ft-
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here Report
eaN liumberisregeriredbyaiicorrtractors
Are you paying with your trust account? 'L, ❑ No
Is tliis a residential o r commercial project? esidential ❑ Commercial
If residential, is it: Single Family Detach d ❑Condo/townhome (single family attached) ❑Duplex
/❑ Muldfamily (apartment) ❑ 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 more? ❑ Yes ❑ No Ifyes, you mayneed to contact Historic Preservation
If this is for a denaoNtion permit, what year was the building constructed?
prior to 1975, you evil/ n d an asbestos assessment to submit with this application.
Description of
'Vol,
:':[f 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 '�4
Elecu-idan_ Plumber- Mechanical Roofer Other
l luoreby acknowledge that.I have read this application and state that the above information is complete and correct. I agree to
Icomply with all requirements contained herein and city ordinances and state laws regulating building construction. I knoliv that a
permit is not valid until it has been paid and issued.
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Print Nam Signature ate — 01