HomeMy WebLinkAbout4510 Seaway Cir - Applications/Gas - Log, Line, Pipe - 05/23/2017Fort Collins
Planning, Development, & Transportation Services
Foi t Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main 970 416.2740 Fax 970.224 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 # b F 7027 Date 5 - - 17
For olirce use on/y
Job Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner Name Address City/State Zip Phone
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Applicad Name Address City/State Zip Phone
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Contractor Address City/State CU Zip Phone
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Co tractor City of Ft. 611ins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number csrequired byall contractors. Are you paying with your trust account? ❑ Yes ❑ No
Is this a residenbal 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 50 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?
Description of work 1 Uri C
*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 Col/Ins 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: A,
Print Name. Signature Date
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