HomeMy WebLinkAbout2161 Romney Ave - Applications/Gas - Log, Line, Pipe - 03/17/2020city o�
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Community Development and Neighborhood Services
281 N College buildingservices@fcgov.com
Fort Collins, CO 80524 970-416-2740
Job Site Address / I '
Address �/ � f �� n� l� (� (/ / i�V e City/State/Zip
Property O ner Inform�a!tion
Name �ohn ICJ i 5e�� %� Phone Number q�U
Address�P % !1< b%� nezda 6' City/State/Zip
Family Detached Q Townhome (attached) Q Duplex QApartmentlCondo
a$ Q Bank Q Bar Q Church Q Hotel/Motel Q Medical Office Q Office
Value of Work
Labor and Materials $
Scope of Work
0 Wood/Pellet stove (required to be EPA approved)
i
Model Name
Manufacturer
VGas Fireplace Length of extensions of gas line (if necessary)
Please list plumber if not completing
Q Garage/Other
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Q Retail Q Restaurant
O Fire Pi
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Additional Inform�at�ett ,,,'�t oq
(if applicable) ' pi1yCJ •J
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Name
Address
Phone K -7
License Number %ice — / pp & � Certificate Number Gl" 3a /--/— r(�
Subcontractor License (if applicable) Subcontractor Name (if applicable)
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Print Name Signature Date
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