HomeMy WebLinkAbout1917 S Shields St - Applications/Furnace - 12/12/2016 (2)Planning, Development & Transportation
Fort Collins 2Fort Collins, OO 80524ege Ave .O. Box 580
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
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating 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 # !JI 0 4q I
forofte ushe only
Date IV -/1-14
30b Site Address (repulied)
Value of Construction (labor, materials, profit)
/
OD
e Address
City/State Zip Phone
mm�iL
`fi1NM115H .
Applicant Name Address
city/State Zip Phone
Contractor Address
city/State Zip Phone
.r-
'FO 39%'4-.ZU-3146
Contractor City of if Collins Sales Tax #
Are you paying taxes here or by report? 18f Here ❑ Report
sales nwnberisregraredbyarlcon&ados
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: _ ❑,ingle Family Detached ❑ Condo/townhome (single family attached) 0 Duplex
`(9Multhrindly (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 Oft If yes, you may need to contact Historic Preservatron
If this is for a demolition -permit, what year was the building constructed?
Ifpn'or to 1975, you wi// need an asbestos assessment to submit with this appJatron.
Description of work
*If lawn sprinider/baddbw preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontr=Wrs: Ust Obe company name of City of R Coffin license 0
Electrician Plumber 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 paws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Name: Signature Date /�
SlS 1 , �-°J �•35-ems' ��./�