HomeMy WebLinkAbout4301 Black Hawk Cir - Affidavits/Homeowner - 11/08/2016PO Box 580
281 N Cotte;e Ave
Fort Collins, CO 80524
970-416-2740.phone 970-224-6134 fax
I/we, iAl-A , as owner(s) of record of the property located
At: �1126 1 V2bAVV- �Wy✓ �� ' , Fort Collins, Colorado, hereby declare and attest
to the following: (please check only the one that applies):
OPTION 1:
❑ I am/ we are acting on my/ our behalf for the purpose of obtaining a building permit and
personally constructing my/our home. The home to be constructed is on the above property and
will be my/our primarV residence. I/we have not personally constructed any other new hornes
in the Fort Collins city limits within the past 2/1-month period.
CPTIQI4 2:
1 am/we are acting on my/our behalf for the purpose of obtaining a building permit and
personally constructing an alteration or addition to my/our house, acting as our own general
contractor. The house to be altered is on the above property and is my/our personal 10,0marl
residence.
O PTIGIq 3:
❑ 1 am/we _ n are acting omy/our behalf for the purpose of obtaining a building permit.and
personally constructing a non-structural alteration to my/our attached single family dwelling
unit. The house to be altered is my/our personal rii a residence. I am aware that I/we
cannot do any structural, electrical, plumbing or mechanical work and Iltiust 11fre
contractors/subcontractors who are currently licensed and insured with the City of Fort Collins.
I am/we are personally performing all of the work or hiring City of Fort Collins licensed trades people, or will be
continuously supervising unpaid volunteers (see Option 3 for attached dwellings). The work is directly related
to the construction of the above referenced horn, which is described more fully on Permit Application it
(obtained from the.Building Services office)..
I/vve understand that any person(s) or. agent(s) contracted to perform structural wood -framing, plumbing,
HVAC, electrical or roofing work, MUST BE licensed contractors in accordance with the regulation of the City
of Fort Collins.
I/we understand that failure to comply with any of the above conditions may result in revocation of any permits
associated with the above Permit Application number, forfeiture of any fees that have been collected, a Slop
Work Order and potentially a court summons.
Sign in the prps6nce of
Owner
.Jr
I Co-owner
The foregoing Affidavit was acknowledged before me on this day of
NoVxk 20 IQ- (month, year) by
Witness my hand and official seal
My commission expires:
.o.
KIANA SADE CARTER
NOTARY PUBLId
STATE OF COLORADO
NOTARY ID 0 20144039424
MY COh4MISSION EXPIRES oCTOBER 09. 2018
Notary Public
Revised 61'1012014.
B1606722