HomeMy WebLinkAbout3474 Shallow Pond Dr - Applications/Water Heater - 01/17/2017CI Of Planning, Development & Transportation
Fort Collins For N. College Ave P.O. Box 580
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 W Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information
ontheapplication. Incomplete applications will not be accepted.
Application # LJC Date
For office use dnly
01 /17/2017
Job Site Address (required)
Value of Construction (labor, materials, profit)
3474 Shallow Pond Drive
$ 1,426.00
Property Owner Name
Address
City/State Zip
Phone
Stacey Shaffer
3474
Shallow Pond Drive, Fort Collins, CO 80528
(970) 690-4211
Applicant Name
Address
City/State Zip
Phone
Keith A. Gallagher
6772 N. Franklin Ave Loveland, CO 80538
970-461-2414
Contractor LIC# MP-37
Address
City/State Zip
Phone
Kahar Plumbing & Heating, Inc.
6772 N.
Franklin Ave. Loveland, CO 80538
970-461-2412
Contractor City of Ft. Collins Sales Tax # 18874
Are you paying taxes here or by report?
❑ Here 00 Report
sales tax number is required by all contractors
Are you paying with your trust account?
IR Yes ❑ No
Is this a residential or commercial project? ® Residential ❑ Commercial
If residential, is it: IN 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
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work Replace 50 gallon water heater - and pan
*If lawn sprinkler/backRow 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 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.
Applicant:
Print Name: Jeff Gallagher Signature Jeff Gallagher Date
01-17-2017