HomeMy WebLinkAbout5620 Fossil Creek Pkwy - Applications/Water Heater - 09/12/2019Fort 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 ❑ Electrical Alteration ❑ Gas Lighter ❑ Gas Log ❑ Heating Unit ❑ Lawn Sprinkler
❑ Mobile Home replacement ❑ Sewer Line ❑ 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 # PJfq rm U Date �2 For office use only .K/n
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Job Site Ad f4ss (required)
Value of Constru 'on (labor, materials, profit)
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Property OwnName
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City/State Zip Phone
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Applicant Name
Address
City/State Zip Phone
Contractor
Address
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City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here ort
%No
Sales tax b r1srequiredbya//contractors
492
Are you paying with your trust account? ElYes
Is this a residential or commercial project? 9 Residen�t'a1 ❑ Commercial
If residential, is it: ❑ Single Family Detached tondo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain
Is this building 50 years of age or more? ❑ Yes No 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
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City 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: n' /-
Print Name: _ 0/ 2MUD\L ti C Signature Date
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