HomeMy WebLinkAbout528 Deines Ct - Applications/Water Heater - 12/03/2018City of
F®rt 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 Line ElPhoto-voltaic
❑ Ventilation Water ater 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 n� 1 C)SL��4— Date I T!_� � II K
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit) I qc .'
Property Owner Name Address
City/State Zip Phone
Applicant Name. Address
City/State Zip Phone
L cl l L.L.
U<> .— '�Z 7-
Contractor Address
City/State Zip Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? Here ❑ Report
5alestax number isrequiredbyall contrad-rs
Are you paying with your trust account?';&Yes ❑ No
Is this a residential or commercial pr)lect? -R Residential ❑ Commercial
If residential, is it: ❑ Single Fami y Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily :jartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bi.r ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain) _
Is this building 50 years of age or t.ore? ❑ Yes ❑ 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 as )e stos assessment to submit with this application.
IPescription of work i ±d e.( V LAC, ( (Ait�f r
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time AIC, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician_ _ Plumber-)"PfZ' L Mechanical Roofer Other
I hereby acknowledge that I have rea( his application and state that the above information is complete and correct. I agree to
comply with all requirements contained ierein and city ordinances and state laws regulating building construction. I know that a
permit is not valid until it has bee.i paid and issued.
Applicant:
PrintName: Li �' Signature v N/� t-- Date