HomeMy WebLinkAbout3450 Lost Lake Pl - Applications/Furnace - 09/24/2019Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that appiy)Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter 13 Gas Log
ZHReating 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.
Application # MIP �7la11�
For office use only
Date 09l2q I2-011
Job Site Address (required) Value of Construction (labor, ma enais, profit)
Wa e. Plat LWJ k2 CoLA5 8057�b DOa
Property Owner Name Address City/State Zip Phone
�c. Avv r• Qti c�MOVA 345o Loft L(kb dace. 'U+ k2 f+ Collins 8oS2
Applicant Name Address City/State Zip Phone
'\Q_An4 5 538Ci'2I Los 4 FA- ' 1 U 00S2'G q o V9` 75 2-
Contractor Address City/State Zip Phone
G)A 9 fi ii C r Gb 8052 970-_4975%
Contrac r City of Ft. oflins Sales T,4x # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tarnumberisrequlredbyall contractors. Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project! 'Res,i.d,rential ❑ Commercial
If residential, is it: ❑ Single Family Detached 12f-Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office i TOffice ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes ❑ No /f yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work AC (0P JCkCV 1#,r,
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
subcontractors: List the company name or City of Ft Coffin license i
Elechklan Plumber mechanical Rooter 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.
PrinApplicant:
m.* 111� �j."� �p ��
Print Nam �1 )U I� 5ignature ' �I Date
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Msion date 2WD17