HomeMy WebLinkAbout816 W Mountain Ave - Applications/Plumbing - 09/26/2016Fort Collins
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 # � 4 (00 ('O�;)'q
For office use only
Date "2�- 10
Job Site Address (required)
Value of Co struction (labor, materials, profit)
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Property Owner Name
Address City/State
Zip Phone
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Applicant Name
Address City/State
Zip Phone
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Contractor
Address City/State
Zip Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report?,8 Here ❑ Report
sales tax number is required byall contractors. Are you paying with your trust account? ❑ Yes _50o
Is this a residential or commercial project? 49t Residential ❑ Commercial
If residential, is it: L1I'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? GXrYes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? 4,b L\
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work Dej—o " fUlb -_0i- SV rJC'4-SZ���r f7L-_
*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. A
Applicant: Print Name: Z<C`` /� �? rrLQ l))
��ln>f�.A_ Signature
Date C?- 26 - 1