HomeMy WebLinkAbout3013 Tulane Dr - Applications/Gas - Log, Line, Pipe - 12/05/2017City of Planning, Development & Transportation
F6Y 281 N. College Ave P.O. Box 580
`�t Collins Fort Collins, CO 80524
�.- Phone 970-416-2740 Fax 224-6134
OVR-THE-COUNTER PERMITS CNLY
This application Is to be used to apply for the following permits only (check all that apply). 0 Air Conditioning
0 Demolition (interior non-structural) 0 Electrical Alteration (not service change) 0 Gas Lighter , 'Gas 67
0 Heating Unit 0 Lawn Sprinkler 0 Mobile Home replacement 0 Roofing 0 Sewer Line 0 Photo -voltaic
0 Ventilation 0 Water Heater 0 Water Line 0 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.
n el Application # 13110 LW 2L' Date I a Z S 11 7
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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V DU .
Property Owner Name Address
City/State Zip
Phone ��
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Applicant Name Address
City/State Zip
Phone qqe
04-t 533._-� &
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Contractorsn Address
City/State Zip
Phone 1710
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KSzl a 13•-?140
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
,0 Here 0 Report
Sales tax num is m b_0cvntractors
Are you paying with your trust account?
0 Yes A No
Is this a residential or commercial project? e< Residential 0 Commercial
If residential, is it: .WSingle Family Detached 0 Condo/townhome (single family attached) 0 Duplex
0 Multifamily (apartment) 0 Garage
If commercial, is it: 0 Bank 0 Bar 0 Church 0 Hotel/Motel 0 Medical office 0 Office 0 Retail
0 Restaurant 0 Other (explain)
Is this building 50 years of age or more? 0 Yes X No If yes, you mayneed to contactHistonc Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*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 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: �r/�
Print Name. Signature
Date /�IJSz / 7
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