HomeMy WebLinkAbout3025 Eastborough Dr - Applications/Gas - Log, Line, Pipe - 11/18/2016 (2)/ Planning, Development & Transportation
,City cif �1/`G� ! 281 N. College Ave P.O. Box 580
®rt Colti s yFort Collins, CO 80524 lit, 194
R.,w� 7 �V ( Phone 970-416-2740 Fax 224-6134 I
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check ail that apply). 0 Air conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement 17 Roofing ❑ Sewer Line ❑ Photovoltaic
❑ Ventilation. ❑ Water Heater ❑ Water Line ❑ WoodlPellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all appli a informa o on the application. Incomplete applications will not be accepted.
Application;, 'Date l / Z i,b //4;,
Forolce use only IR
Sob Site Address (required) I Value of
Construction (labor, materials, profit)
3Do1.5 45)%o�F`OuhcJ br. $ /-75 g�2
Property Owner Name
X<tVir3 oort--
Address
3a.75 .a
City/State
bosoms h Dr, R"C•
Zip
dsa5
Phone
(ego aq��
Applicant Name
Address
City/state
Zip
Phone
Contractor Uc # Address
liweric ar 4a 4Ie- %1-!73a
Contractor City of Ft. Collins Sales Tax # J 934/ f
Safes tax number is requlmd byaff conbadors
City/state Zip Phone
Sr #F Al nJ.sor do. 9v3]6o 970 &W&Af
Are you paying taxes here or by report? 0"Pere C! Report
Are you paying with your trust account? Yes . ,,.0'No
�6d�of AGfrG�
Is this a residential or�comercial project? UKesidential ❑ Commercial
If residential, is it: Mingle Family Detached ❑ Condo/townhome (single famlly attached) ❑ Duplex
❑ Multifamily (apartment) 0 Garage
If commercial, is it: ❑ Bank ❑ Bar 0 Church ❑ Hotel/Motel ❑ Medical office ❑.Office O Retail.
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? 0 Yes E"o If yes, you may need to contact Historic Preserlratton
If this Is for a demolition permit, what year was the building constructed?
If pNor to 1975,: you -wlll need an asbestos assessment to submit with this appl/catlon.
Description of work
V lawn sprinkler/backflow preventer, must list licensed plumber. If first-time. A/C, must list licensed electrician..
Subcontractors: L& the company name or Qy off? Collins license #
Electrician WO r rY&l tzke e, Plumber Mechanical Roofer Other
i
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 statelaws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant., l�r /
Print Name: "''�Y lI Signature Date �� ��