HomeMy WebLinkAbout1136 E Stuart St - Correspondence/Zoning - 11/02/2016HEALTH FACILITIES AND E�IJ?RGEN'V
MEDICAL SERVICES DIVISION
4300 Cherry Creek Drive South State Lieensure Program
Denver, CO 80246
Voice: 303-692-2800 Far: 303-753-6214 Home Care Agency
w-%vw.edphe.state_co.us/hf ifd_asp
ZONING DEPARTMENT
Sign off for Local Authorities
Colorado Department
of Public Health
and Environment
Written evidence of compliance with local zoning codes nurst be obtained prior to issuance of a state license for
operation of a health facility/agency. Contact the city or county department in your area and have the director or
designee sigi: below. The original signed fornr nurst be returned to Health Facilities and E`nergency 1111edical Services
Division (HFEMSD) as part ofyoier application packet.
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE Of APPLICATION
® Initial
] Addition of Branch Location
] Change of Location: From.
SECTION B: TO BE COMPLETED BY THE APPLICANT
Current Name of Agency: AGC In Home Services LLC
Proposed Name of Agency (if applicable):
Address:1136 E Stuart St Ste 4201 Fort Collins Larimer
City County
Name of Person to Contact: Alan Romero Phone: (A70) 300-3414 Fax: (970)-MQ-3414
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY ZONING DEPARTMENT
Zoning Department having Jurisdiction: LiTl 0% 0AT C" t5
The above-nained agency meets the requirements for zoning approval: J>4 YES [ I NO
(If "no" please explain on a separate attachment.)
Signature: �—` Date: //-(�?-/1
Name ofPerson to Contact: ARCl.eS 644L,5G�rJ Phone: (g70 1 yj6 z Fax: 070) y/6 y� -
Address: ,9?61 /�) 64GE60-0 Az /,G;eT 64-41'e,5- 0 ���