HomeMy WebLinkAbout5846 Mercury Dr - Applications/Air Conditioner - 12/01/2016City Of j Planning, Development & Transportation
281 N. College Ave P.O. Box 580
®rt Collins Fort Collins, CO 80524
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 Hater ❑ 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 # r I /O� / /� �f � Date
For o/i9ce irse only " P� t lit l--F 1 " ( ,
Job Site Address I
lre9uinvl
Value of Constru n (labor, materials, profit)
� !
3 ;ISM, 3�8
Property Owner Name i I' Address
City/State Z. Fj092c� Phone q 10
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ZZ3
Applicant Name Address
CI
Ci /State Zip Phone q 7 D
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1—E_(.a"ci 1.i c; 3"1 - I / TO
Contractor J J Address
City/State Zip 305 3 J Phone 0-10
RO i s �,, a � �, � ` /�i Y 43 �
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by. �acontractors.
Are you paying taxes here or by report? p Here ❑ Report
53 2-r�
Are you paying with your trust account? D Yes ❑ No
Is this a residential or comrIiercial project? Residential ❑ Commercial
If residential, is it: CSingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of, age or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preseruadon
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will neeW an asbestos assessment to submit with this application.
i
Description of work I
C Q
t
I
*If lawn sprinlder/backflow p'eventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the coinpany name or Oty of ft Collins license
I
Electrician i lumber Mechanical Roofer Other
I hereby acknowledge that I
comply with all requirements
permit is not valid until it
Applicant:
Print Name:_ -
read this application and state that the above information is complete and correct. I agree to
ained herein and city ordinances and state laws regulating building construction. I know that a
been paid and issued.
SC I C, Wr Signature /t l il%j \r' 41 h l ll t� _ Date l 21 D i �/ lP