HomeMy WebLinkAbout1301 S Shields St - Applications/Water Heater - 12/15/2017City 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 # b� 4 Z Date
For oB%e use only
Sob Site Address (req iredI Valuesof Construction (labor, materials, profit)
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Property Owner Name Address City/State Zip Phone C3 7 o
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Applicant Name Address i q City/State Zip Phone q ?U
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Contractor Address City/State _ Zip Phone
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here (wrt
Sales tax number isrequlmdbyall contractors. Are you paying with your trust account? ❑ Yes n-110
Is this a residential or coTpwemial project? Residential ❑ Commercial
If residential, is it: ingle 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 plain)
Is this building 50 years of age or more? ErYesONo 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 k t-p L4 6(�s Gfi 4 7 �e 9V--,4 F cP
*If lawn spnnkler/baddiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Cty 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:
Print Name: Signature Date ya l 7
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Revision date 2/6/2017