HomeMy WebLinkAbout1917 S Shields St - Applications/Furnace - 01/02/2019 (2)Fo t Coltins
Planning, Development a Transportation
281 N. College Ave P.O. Box 580
Fort Collins, M 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 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.
vv Application # 1q Date �4 2
For use only
lob SRO Address (required)
Halua Of Co:.s nKtk n (Iabor, materials, profit)
&50 -o d
Property Name Address
city/State Zip `` Phone
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Applicant Name Address
City/Stale Zip Phone
Contractor Address
City/State Zip Phone
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Contractor City of It Collins Sales Tax #
f Are you paying taxes here or by report? -Here ❑ Report
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Are you paying with your trust amount? ❑ Yes ❑ No
Is this a residential or commercial project? MItesidential ❑ Commercial
If residential, Is it: O Single Family Detached O Condo/bowmhome (single family attached) ❑ Duplex
Multifamily (aparbnent) a Garage
If commercial, Is it: 1113ank 13 Bar ❑ Church O Hotel/Motel ❑ Medical office 13 Office ❑ Retail
13 Restaurant E3 Other (explain)
Is this building 50 years of age or more? O Yes O No If yes, you may need to contact Historic PresenafYon
If this is for a.demoiiti?an Permit- what year -was the building constructed!?
Ifprior to 1975, you will need an asbestos assessment to submit with th/s applkation.
Description of work
"'If lawn sprinkler/baddlow preventer, must list licensed plumber. If first-time A(C, must list licensed electrician.
Subconbactors: List Ghe company name or 01y of Ft Collins IA=ste #
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 Dale J'� l /
Print
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