HomeMy WebLinkAbout2155 Orchard Pl - Applications/Furnace - 08/21/2017City 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 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. Incomplete applications will not be accepted
Application # V)O b4G$� Date S 1 Zi Izot
%
For office use only
Job Site Address (required) 0^''+ pie Value of Construction (labor, materials, profit)
1S2O o?c,"" P2 . E-v 9--7 1 zoo -
(Property Owner Namen� Address City/State Zip Phone
U yin i• • , ^`� U `&�l 4 cl t. JZ �; Ir : , �f �%'� - a,2/2-2,�-% j
Applicant Name Address City/StZi Phone
t3 � y 1-0 ate bb2PjZ s7 -2- o sl7
ContractorT—YS; S1�16/%q° Address City/State Zip Phone 940
P QA oluffs l A Imo ° f3ol-t_ 1 0 & Lk-L4j S
Contractor City of R. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here eport
Sales tax number Isrequired byall contractors. Are you paying with your trust account? ❑ Yes ❑ o
Is this a residential or commercial project? denbal ❑ Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
T.�amity (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 year: of age or morel ❑ 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#+C_C_ eCe
*If lawn spnnkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gil of Ft Collins license #
Electrician Plumber 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: ynp�/
Print Name: / e) orod Signature Date
Revision date 2/6/2017