HomeMy WebLinkAbout2226 W Elizabeth St - Applications/Water Heater - 08/22/2017City 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) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating U it ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ater 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 # U 1fo10 `T� 3 Date y 2^
For office use only
Job Site Address (required) Value of Co struction (labor, materials, profit)
Pro erty Owner Name Address City/State Zip Phone
Applicant Na a Address City/State Zip Phone
�.c.7 (k/?�►S
CoqZactor_,Address; City/State Zip hone
Contractor City of R. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax num is ui byaamntractors. Are you paying with your trust account? Xes ❑ No
Is this a residential or commercial project? `Residential ❑ Commercial
If residential, is it: le 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 W
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*If lawn sprinkler/backfiow preventer, must list licensed f first-time A/C, must list licensed electrician.
Subcontractors: List the company name , of Ft Collins license #
Electrician er 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: 7,� J '%
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Print Name: � r / V � J ` Signature DateWV r
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Revision date 202017
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