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HomeMy WebLinkAbout3215 Bryce Dr - Applications/Gas - Log, Line, Pipe - 07/22/2016planning, Development a T ransp©rtaLilen clay ' 281 N. College Ave P.O. Box 580 %rt ©i ons 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 Lighterlz�as-1=eg ► i've_-Pll ❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line 0 Photo -voltaic ❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and manufacturer). Complete all applicable info rmati n on the application. Incomplete applications will not be accepted - Application # ���� a�-� Date For office use only Job SEte Address (required) Value of Construction (labor, materials, profit) Property Owner Name l Address CityJState Zip BY- «95S,-Z5- Phone "I70 6�v--78� Applicant Name Address _ -- City/State 1 Zip Phone 64. f �•�.�f4.i� irk. t��'IE Js? ��: ,l F cr-1 ��- dq f�:_� Co tractor Oc Y Address City/State Zip, Phone U ")3 Contractor City of Ft. Collins Sales Tax T Are you paying taxes here or by report? 2 Here ❑ Report . Sales tax number is required by aff co%69211_ Are you paying with your trust account? ❑ Yes ❑ No Is this a residential or commercial project? residential ❑ Commercial If residential, is it: JJ2 Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex ❑ Multifamily (apartment) ❑ Garage 11 commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel - ❑ Medical office ❑ Office ❑ Retail ❑ Restaurant ❑ Other (explain) Is this building go years of age or more? O Yes O'No lfyes, you may need to contact Historic Preservation if this is for a demolition permit, what year was the building constructed? Ifpricr to 1975, you aril/ need an asbestos assessment to submit w1rh this applicafion. of 1f lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed eleCsician. subcoritractom: List the company name or City oFFt 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. s know that a permit is not valid until RE has been paid and issued. AD P Icanrt. `� / �' / �GZGC� Print Name :�l� Signature Date 7/ z� l