HomeMy WebLinkAbout701 Gallup Rd - Applications/Water Heater - 01/06/2020Fort 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 informatio on the application. Incomplete applications will jnot be accepted.
Application # 1r1 �1 kl�'1 Date 12/31/19 l ® I'6 - Y)i
For ofce use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
701 Gallup Road
*( a a a . g 5
Property Owner Name Address
City/State Zip
Phone
Sam Mitchell 701 Gallup Road, Fort Collins, CO 80521 USA
(970) 443-8569
Applicant Name Address
Citv/State Zip
Phone
4600 Innovation Dr. Suite 102 Fort Collins CO 80525
970-399-9940
Contractor Address
City/State Zip
Phone
Benjamin Franklin Plumbing 4600 Innovation Dr. Suite 102 Fort Collins, CO 80525
970-399-9940
Contractor City of R. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Report
sales tax number lsrequlredbyallcontracto
a you paying with your trust account?
Yes ❑ No
52310
Is this a residential or c mercial project? Q Residential ❑ Commercial
If residential, is it: EI Single Family Detached ❑ Condo/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
.IW
*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 a 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: 1(�f p� p �I1 p �T p -�
Print Name: � 1 i� u I � C, a 5y 4'� Signature a 12/31/19