HomeMy WebLinkAbout114 Bristlecone Dr - Correspondence/Zoning - 06/15/2016COLORADO
Office of Behavioral Health
Department of Hurnan Services
SUD —Substance Use Disorder State Licensure Program
ZONING DEPARTMENT - Zoning Use Confirmation - Sign off for Local Authorities
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF THE APPLICATION:
Type of Substance Use Disorder
services being provided:
❑ Initial Application
❑ Renewal Application
8 Modification - Change in location
❑ Residential / Transitional 0 Outpatient ❑ Day Treatment
SECTION B: TO BE COMPLETED BY THE APPLICANT - PHYSICAL SITE LOCATION
Current Name of Agency: SummitStone Health Partners
Address: 114 Bristlecone Drive
City: Fort Collins
Name of Contact Person for any questions
Zip: 80524
Cheree Carlson
Phone: (970) 494.4200 Fax: (970) 223.0896
County: Larimer
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY ZONING DEPARTMENT
(this section must be filled out by the proper authority to be considered a valid document)
Zoning Department having jurisdiction: L7/71
The above named facility meets the requirements of the local authority having jurisdiction for the occupancy
based on work outlined above. (If "no", please explain on a separate attachment) RYES ❑ NO
Signature:�r� Date:
Printed Name: Al/ eCGIS � S�04} ' Title: 76,v1N6 ,rJS�EG%f C
Address: ,-:?01 /U 6_4x lloos City: /�r 61_6 ells Zip: c ,�
Revised 08/21/14