HomeMy WebLinkAbout6714 Beverly Glenn Ln - Applications/Water Heater - 11/15/2016NOV/15/2016/TUE 09:53 AM FAX No, P,003
Fort Collins
Planning, Development & Transportation
281 N. College Ave P,Q, Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER -THE -COUNTED 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 i"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 III not a accepted.
Application # 1J�`Q.
For ofce use only
Date
Job Site Address (required)
Value of Construction (labor, materials, profit)
U-114 i c
, 2-
Property Owner Name Address
City/State Zip.
Phone
w
- ui
Applicant Name Address
City/State Zip
Phone
_
7-
Contractor Address
City/state Zip
Phone
?L
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
Sales taxrrr�l berisreq iredbya#contractors
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? Er 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 5o years of age or more? ❑ Yes EONo If yes, you may need to contact Historic Preservation
If this Is for a demolition permit, what year was the building constructed?
If pr1or to 1975, you will need an asbestos assessment to subm/t with this application.
DescriAtion of work
*If lawn sprinkler/backflow preventer, must list licensed plumber, Ir 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: mi, `�
Print Nae:,] � I � L_fY„ Signature
(Date 11 15 i (.a