HomeMy WebLinkAbout1040 Glenmoor Dr - Applications/Gas - Log, Line, Pipe - 01/30/2017City of
/0"' � t Collins
Planning, Development & Transportation
281 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 apply4or the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) V 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 # b I �] 00 LA 5 9 Date 1 - 30 —11
For oliice use only 50 O O
)ob 'te Address (required) Value of Construction (labor, materials, profit)
o _1 10�0 ClcnMoor� Ar. for4 C011IA5 Co Nogg q70-211.-06
Property Owner Name Address
S C6 IOZOAiZk IDqo Clenn6or-
City/State Zip Phone
�r. FOr4 C0111-/Vs CO e652 q�0-z.lR-G68
Applicant Name Address
City/State Zip
Phone
Contractor. Address
City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by all contractors.
Are you paying taxes here or by report? Here
Are you paying with your trust account? ❑ Yes
❑ Report
to
Is this a residential or�co mercial project? Q'Residential ❑ Commercial
If residential, is it: D'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 o tf yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work Ln 1 Ilailio of new oicis line-- m4 elects-leA1 OuHO Fdr
a e W - z-r r i t
r in er-i Wi 1 in +011COV bi a Pre PIAC(- COn Trac or —
*If lawn sprinkler/backflow 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: ) Acd)5 to fNA12"0 Signature
Date 1 /31
83