HomeMy WebLinkAbout2221 Clipper Way - Applications/Gas - Log, Line, Pipe - 09/13/2016Planning, Development: a a ranspog taeiort
®� 281 N. College Ave P.O. Box 580
,. et olbns 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 _ 0 Gas_l
❑ Heating Unit ❑ Lawn Sprinkler ❑ WIobile 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 information on the application. incomplete applications will not be accepted -
Application # pJ I te d 5 H 6 L4 Date .3
For orrice use only
Job Site Address (required) Value of Construction (labor, materials, profit)
2 �_ z l 0- l 'PP61- tcJ�(_y $ Z0619 . o L-)
Property Owner Name Address
City/State Zip
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Applicant Name Address
Gty/State ,o �' Zip
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Cgntractor Lic r Address : City/State i Zip,; d Phone
Contractor City of Ft. Collins Sales Tax
Are you paying taxes here or by report?
}Here ❑ Report .
Sales tax number is required by allcona60?a__
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? 0 Residential ❑ Commercial
if residential, is it: A Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) 0 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 A No if yes, you mayneed to contact Historic Preservation
if this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
"If lawn sprinkier/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors., List the company name or Cry 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. 1 know, that a
permit is not valid until it has been paid and issued.
Applicarlic
Print Nail. b2 6 �L�'L Signature
Fate ��
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