HomeMy WebLinkAbout403 Stout St - Applications/Backflow - 07/14/2017City of Planning, Development, & Transportation Services
Fort 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) 0 Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ArLawn 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.
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Application #�(�) �b � � 0 Date 711-r117
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner Name Address City/State Zip QPhone
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Applicant Name Address City/State Zip Phone
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Contractor Address City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? aHere ❑ Report
Sales tax number is required by all contractors. Are you paying with your trust account? ❑ Yes ER No
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Is this a residential or commercial project? aResidential ❑ Commercial j
If residential, is it: ER Single Family Detached ❑ Condo/townhome (single family attached) ❑ DuplexnL ^
❑ 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 /3•-/r /tic✓
*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 #
Electrician Plumber ��-�L� 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:
Print Name: �d"% � Signature Date
Revision date 2162017