HomeMy WebLinkAbout5102 Northern Lights Dr - Applications/Gas - Log, Line, Pipe - 08/22/2017City Of Planning, Development & Transportation
6r"t CAt� For N College Ave P O Box 580
V .\7 Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OSIER -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
Application # � 1-40 *Z'.
For ofce use only
Incomplete applications will not be accepted
Date .3a 17
Job Site Address (required)
I; a�#� '
Value of Construction (labor, materials,
profit)
Property Owner Name
Address
City/State Zip
�*
aLea-
Phone
Applicant Name
Address
City/State 4j Zip
Phone
Address
Contractor City of Ft Collins Sales
Sales tar number is required by all mnbac
City/State Zip
Are you paying taxes here or by report7,21iere ❑ Report
Are you paying with your trust account? jd'yes ❑ No
Is this a residential or commercial prolect7 2rTQdenbal ❑ Commercial
If residential, is it vErSmgle 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 Hlstonc Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975 you wdl need an asbestos assessment to submit with this anPfi lion
Description of work
*If lawn spnnkler/backFlow preventer, must list licensed plumber If first-time A/C, must list licensed electrician
Subcontractors: Llst the company name or Oty of Ft Collins license #
Electncian PlumberAl�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 Nam SignatuJeLZ9_'�A%CDate ,r