HomeMy WebLinkAbout155 Circle Dr - Applications/Water Heater - 07/07/2017Fort Collins
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 ❑ 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 Informationonthe application.
Application # � l
1 0� 3
For office use only
Incomplete applications will not beaccepted.
Date -7/-7, 1-7
115
JWSite Address (required)
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Value of Construction (labor, materials, proft)
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Property Owner Name Address
City/State Zip Phone
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Applicant Name Address
City/State Zip Phone
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Contractor (,u5rOM 1-IT�9 4 a`iK- Address
City/State Zip Phone
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Contractor City of FL Collins Sales Tax #
Are you paying taxes here or by report? Mere ❑ Report
Sales tax number Is required by allmnbactws
Are you paying with your trust account? ❑ Yes
Is this a residential qrFommercial project? P�-R
If residential, is it: Single Family Detached
❑ Multifamily (apartment)
If commercial, is it: ❑ Bank ❑ Bar ❑ Church
sidential ❑ Commercial
❑ Condo/townhome (single family attached)
❑ Garage
❑ Hotel/Motel ❑ Medical office ❑ Office
❑ Duplex
❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes ❑ No Ifyes, you may need to contactH&Wdc Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprfor to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*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 Collins license #
Electridan Plumber Mechanical �A % 004 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. 11, _
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