HomeMy WebLinkAbout301 E Prospect Rd - Applications/Gas - Log, Line, Pipe - 05/04/20165,-- (1, e
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 non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating 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, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # 510 0 21 l - 12 Date 5/04/2016
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
301 E. Prospect
$ 1,070.14
Property Owner Name
Address City/State Zip
Phone
Libby Nikkei
301 E. Prospect, Fort Collins, CO 80525 310-699-3008
Applicant Name
Address City/State Zip
Phone
Keith A. Gallagher
6772 N. Franklin Ave Loveland, CO 80538
970-461-2414
Contractor LIC# MP-37
Address City/State Zip
Phone
Kahar Plumbing & Heating,.lnc.
6772 N. Franklin Ave. Loveland, CO 80538
970-461-2412
Contractor City of Ft. Collins Sales Tax # 18874 Are you paying taxes here or by report?
❑ Here DO Report
Sales tax number is required by all contractors
Are you paying with your trust account?
[A Yes ❑ No
Is this a residential or commercial project? ® Residential ❑ Commercial
If residential, is it: [.A 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 50 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 will need an asbestos assessment to submit with this application.
Description of work Gas to fireplace - Underground gas to BBQ/Firepit - H O f+
*If 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 #
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:
Print Name: Jeff Gallagher Signature Jeff Gallagher Date 5-04-2016