HomeMy WebLinkAbout1805 S Shields St - Applications/Furnace - 10/07/2016City of
Fort 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 # L. 4 V�� DUIq-4Date %6
For office use only
Job Site Address (required)
Value 0` C.o:rs°tlru: Lion (labor, materials, profit)
Property Owner Name Address
City/State Zip Phone
6, Sao-" S fa,� - �7s�
Applicant Nam Address
City/State Zip Phone
Contractor Address
City/State Zip Phone
Contractor City of F . Collins Sales Tax #
Are you paying taxes here or by report? )9f Here ❑ Report
Sales twnumber & required byall contractors
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: ❑ 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 S® years -of age or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If pr/or to 1975 you W// need an asbestos assessment to submit with this application.
Description of work
*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. / g � x/ & - /
Print Name: � �,f9.r ./-/�! � K � Si nature �� ;uLc_/� . �f�C�- Date � �' �Ca