HomeMy WebLinkAbout1524 W Lake St - Applications/Water Heater - 12/23/2016:i
1 Planning, Development•&,Transportation
City o'f' 281 N. College Ave P.O. Box.580 ,
Fdf t Collln5 Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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V _aT = PERMITS ONLY
This ; application _,Is to be used to apply for the following permits only (check all that apply). 13AirConditioning
'O Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter. ❑ Gas tog
❑'Heating Unit O Lawn Sprinkler O Mobile Home replacement, O Roofing ❑,Sewer line O Photo, voltaic
O Ventilation Ik,Water Heater 13 Water Line ❑ Wood/Pellet;Stove (must be EPA certified, provide make; model and
manufacturer): 1 1'
Complete all applicable information
/won the application. Incomplete applications will not be:accepted.
Application # { U ��-' I tl� I��
date
or ollice use on/y
Job Site Address: (raqulred)
Va ue of Construction (labor, materials, profit)
� D ,tea.
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Property Owner Name
Address City/State . Zip
Phone
CO(�-� bLL
SZf N;.�q.Q A/s11A0 �L. Co $oszl
Applicant Name $
Address City/State Zip,
Phone
Contractor {
5�10 �J►r,
Address City/state Zip ,`
ftol) �6 wl� RJR
Phone
o. 17
: i'vMbt�► s
>` �, 0
97 y'(o(o-.i'
Contractor City. of Ft. Collins, Sales Tax:# Areyou paying taxes here or by rep orr?
O Here Report
soles taxnui7b&isieq&i &byaffao rractbis. Are'you paying with your trust account?
Sl�
O Yes No
Is this a residential or Commercial project? Residential :❑ Commercial
If residential, is it:l O[Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex, .
i 0 Multifamily (apartment) 0 Garage
'If commercial; is If: 13 Sank, O Bar O Church ❑ Hotel/Motel ❑ ;Medical office E7 Office - ❑:Retail
' O, Restaurant O Other (explain)
Is this building 50!years of age or more? .O Yes 0. No. IfYes, you may need to contact Historic P.Th=rvatizrn
If this:is fora demolition permit, what year was the building constructed?
Ifprior to 197_s, you will need an, asbestos assessment to submit with this application.
;.
Description of work `ROD 1/}r WT,h S v►9!{
*If lawn sprinkler/backflow preventer, must list -licensed plumb6r. If first-time A/C, must list licensed electrician.
Subcontractors: Gist the company name or City of Ft Collins license rr
Electrician Plumber _ 11D Mechanical Roofer Other'
E.
I hereby acknowiedge, 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 regulabrig..building construction. • I know that a
permit is not valid'until;it has',been,paid and issued.
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Applicant: � j /1//'
Printidame: I /, tS,Z, ���t Signature Date