HomeMy WebLinkAbout821 Elm St - Applications/Water Heater - 06/30/2017City, of
Fort Cothns
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 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 ❑ Rooting ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation 9 Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable Information on the application. ti
Application # 110 J
For office use only
Incomplete applications will not be accepted.
Date 1-30—/7
lob Site Address (requtred)
Value of Construction (labor, materials, profit)
?a 1 Ec s
- C o- _rA--d '
Property Owner Name Address
Z'4^
City/State Zip Phone
6 300
1'* ST C
Applicant Name Address
City/State Zip Phone
3t6Y 4 r M!/ //.10 N, i4
;// dl �f - a043a/ .9/7 v6 da�
Contractor Address
City/State Zip Phone
Contractor City of FL Collins Sales Tax #
Are you paying taxes here or by report? JXHere ❑Report
Sales tax number Isrequ/mdbyaffcw&actofs
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? I& Residential ❑ Commercial
If residential, is it ❑ Single Family Detached ❑ Condo/townhome (single family attached) "S Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Offlce ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ` W No Ifyw, you may need to contact H&WItc Pmmnwbbn
If this is for a demolition permit, what year was the building constructed?
Ifpdor to 1975, you wi// need an asbes&w assiamerrt to ,submit w/bh ih/s app/lotion.
Description of work 04 cre 4f
*If lawn sprinkler/baddiow preveriber, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or aly of Co//Ins license #
Electrician Plumber Mechanical Rpm 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. GG
Print Name: `s ! / iZ 4t�4 K11 Signature
Date 4-30--1?