HomeMy WebLinkAbout3025 Eastborough Dr - Applications/Gas - Log, Line, Pipe - 11/18/2016of A,/G� / Planning, Development &Transportation
Flirt CoColonsCity
'"L J"r L0 / For N. College Ave P.O. Box 580 4A194
f Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
/
OVER -THEE -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 appliqaLble informa o on the application. Incomplete applications will not be accepted.
A lication # I� Date 1/ IS /JL
PP
For office use only
lob Site Address (required) Value of Construction (labor, materials, profit)
30�5as��d�ac� fir•. $ 97�
Property Owner Name
KegirJ ooYe
Address
30,25 _a
City/State
horeL- A or, l=C•
Zip
S05.25
Phone
490 a904
Applicant Name
Address
City/State
Zip
Phone
Contractor Lic # Address City/State Zip Phone
lwe r-k.me 4Ae- %f ' l 1:W 5 to ( r ��r��n d� I/, nJSor eo . 6'a 5.;C 970 &W&0� 41
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ere D Report
sales tax number is required by all contractors `� ���( Are you paying with your trust account? Yes ,vEl'No
ep rwoY '0G6rri�
Is this a residential or�co mercial project? [B'9esidential ❑ Commercial
If residential, is it: tf 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? ❑ Yes LPNo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975,. you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time. A/C, must list licensed electrician..
Subcontractors: Llst the company name or City of Ft Collins license #
Electrician w, rP� se e, 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: r
Print Name:—`''� Y [� Signature
Date ///'la ��