HomeMy WebLinkAbout1636 Northbrook Dr - Applications/Reroof - 02/21/2018Fcity of 281lirt Collins For N. CollegeCI Ave P.O. Box 580
Fort Collins,, CO 80524
Phone 970-416-2740 Fax 224-6134
OVEWTHE-COUNTER PERMITS ONLY
514D
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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 0 Lawn Sprinkler 0 Mobile Home replacement 0 Roofing ❑ Sewer Line 0 Photo -voltaic
❑ Ventilation 0 Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable
eiinformetion on the application. Ineomploto applications will not be accepted.
Application # 1 0 2 SIDate � C9100
Por on —Ice use only
_. ... ...... .......... .
Sob site Address (requlmd) Value of Construction (labor, materials, profit)
Property Owner Name Address City/State Zip Phone
Applicant Name Address ity/State Zip Phone
Col)tRctor Address City/State zip phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? 6 Here O Report
Awes = numtW is regWred by a# cantracmrs: )�� ?�"7 Are you paying with your trust account? ❑ Yes dd No
Is this a residential or commercial pro)ect? 4P Residential ❑ Commercial
If residential, is it, ❑ Condo/townhome (single family attached) Duplex
0 Multifamily (apartment) C3 Garage
If commercial, is It: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building So years of age or more? ❑ Yes 0 No If yes, you may need to contact Histor/c Preservation
If this is for a demolition permit, what year was the building constructed?
DescriptionAf work
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must. list licensed electrician,
Subcontractors: List the company name or Gty of Ft Collins license #
Electrician Plumber Mechanical Roofer Other
I hereby acknowledge that I nave 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 (� /Z/r ` i
Print npme \ CCC���� �% Signature Date ' ��l