HomeMy WebLinkAbout5124 Stillwater Creek Dr - Applications/Water Heater - 01/16/2017ins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
UOVER-THEmCOTE PERMITS ONLY
This application is to be used to apply for the following permits only.(checic all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
f3'�laating 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, modal and
manufacturer).
Complete all applicable information on the a PlIcation. incomplete applications will not be accepted.
Application #
1 Date
Sob Site Address (requir-W Valve of Constmction (labor, materials, profit)
512y S 1\ Cc< k Or un;� D 'W gos2F! 3 0Z%V—
Address City/State Zip Phone
Property Owner Name �S
L t 22 $uoar! tr+w G. Hnus �'- '/02�
r ol�ta� 1?'►�1 el�►� 7--
Applicant Nam
U Address City/Sure zip Phone
is
,lAern r
Contractor
Address Clty/State Zip Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here 'JgReport
,al:T taN numberirrequiredbyall contractors. Are you paying with your trust account? -yes ❑ No
ItDA,/fl
is this a residential or commercial project? esid �n ❑ Commercial
If residential, is It: ❑ Single Family Detached [3 Condo/townhome (single family attached) ❑Duplex
❑ Multifamily (apartment) ❑ Garage
Ir 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 mntactHfstorlc Preservation
If this is for a demolition permit, what year was the building constructed?
If prior tv 1975, you will need an asbestos assessment to submit with this application.
Description of work e Yn a �� ' ' ° �°c vR9+--ck_`t` I � � 1&AL_n
W hl C i
14If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the cvnlpany name or Cty of Ft Collins license #
Electrician Plumber
Mechanical Roofer — Other
f 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: e -I.,
Print Nam Signature ate