HomeMy WebLinkAbout5125 Stetson Creek Ct - Applications/Water Heater - 12/06/2017Cityof
Fo t Collins
Planning, Development & Transportation
281 N College Ave P O Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 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 Lane ❑ Photo -voltaic
❑ Ventilation X 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 # \2)1-46WDate
For office use only
Job Site Address (required)
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Value of Construction (labor, materials, profit)
30V
Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
City/State Zip
Phone
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Contractor Address
City/State Zip
Phone
6ar as COP- M,
Contractor City of Ft Collins Sales Tax #
Are you paying taxes here or by report?
❑�./Here El Report
Sales tax number is required by all contractors
1�i3'1 t
Are you paying with your trust account?
q7 Yes ❑ No
Is this a residential or commercial projects & Re'siliential ❑ Commercial
If residential, is it ❑ Single Family Detached N Condo/townhome (single family attached)
❑ Multifamily (apartment) ❑ Garage
If commercial, is it ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office
❑ Duplex
❑ Retail
❑ Restaurant ❑ Other (explain)
is this building 50 years of age or more-) ❑ Yes ',,i No If yes, you may need to contact Historic 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 thls application
Description of work E�p 1 e ,a SU 616Wl)Vt 116 VILI ( I��LS bV (lfi Ql�r �^2Cli Q�.
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"If lawn sprinkler/backflow preventer,, must list licensed plumber If first-time A/C, must list licensed electrician
Subcontractors: List the company name or Oty of Ft Collin 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: C
Print Name `Jeri `,'�ect"U' Signature �t�OlrmN'\' Date G +�
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