HomeMy WebLinkAbout2103 Bock St - Applications/Sprinkler - 11/20/2017Planning, 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 # 1J 1-1 ID -1 9 a LA Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name Address City/State Zip Phone
lC'1 I-/an-3 L/Od/ $057elw
Applicant Name Address City/State Zip Phone
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Contractor Address City/State Zip Phone
=pS /l // '0 v". es�- eJ05%z -/ Pa-
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? a Here ❑ Report
Sales tax number IsrcgWredbyall conhadors Are you paying with your trust account? ❑ Yes EB-No
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: M-Single 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 Erft If yes, you may need to contact Historic Preservalion
If this is for a demolition permit, what year was the building constructed?
Description of work
*If lawn spnnkler/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 PlumberM,4 ! /d 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: ---o^ �/`�d //1,2al i
Print Name: % Signatu Date
Revision date 2 O17