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HomeMy WebLinkAbout1204 E Pitkin St - Applications/Reroof - 11/30/2016•:•:., c'i Planning, Development, & Transportation Services Fcirt Collins Community Development & Neighborhood Services 281 North College Avenue Fort Collins, CO 80524 -970.416.2740 OVER-THE-COUNTER PERMITS ONLY This application is to be used to apply for the following permits only (check all that apply). El Air Conditioning ❑ Demolition (interior non-structural) ❑ Electrical Alteration (not sere ce change) ❑ Gas Lighter ❑ Gas Log ❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement 9 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 #— I . VJ Date For office use only ]ob Site Address (required) Value of Construction (labor, materials, profit) Property Owijer Name Address City/State Zip Phone l'Ji v ^' Enl(' lAVG/ Li rls0f !`vni.r i.% s iJ. %� /�1%ir i :lv Applicant Name Address City/State Zip Phone 'V j ;.;10 P• (%r . C' J y.;,_1.. j..✓?; `�..If ,r i� Contractor Address City/State Zip Phone j.:.; C, l / l.;' is l e r 0w Contractor City of Ft. Collins Sales Tax # > Are you paying taxes here or by report? EI"Here ❑ Report Sales tax number is requxed by all contractors. - "� Are you paying with your trust account? ❑ Yes I52/No Is this a residential or commercial project? EdResidential ❑ Commercial If residential, is it: Lff"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 r, ❑ Restaurant ❑ Other (expl Is this building 50 years of age or more? ❑ Yes 0 No If yes, you may need to contact Historic Preservation If this. is -for a. demolition permit, what year.. vas the. build ing.construct ed? . __ --- --- -- ------ ----------- Description of work { : t rr i -' i ! �; i .' i V"1 t ' i t; J'r , Y_�i "t / % i I P. �' (J r�1 / : J -'-- --- *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 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. Print Name:: Signature ! _— i r — ©ate - R! isNd 11i23/2016