HomeMy WebLinkAbout924 Alexa Way - Applications/Water Heater - 02/01/2017FEB/01/2017/WED 10:08 AM FAX No, P,003
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City of Planning, Development & Transportation
261 N. College Ave P.O. Box 58o
art Cottons fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134 S
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 Hester ❑ 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 # > �Iap Date I�
For office use only
Job Site Address (required)
Owner Name Address
ADollcant Name, Address
Contractor Address
Contractor City of Ft Collins Sales Tax #
Sales tax number Is mq ( all
Value of Construction (labor, materials, profit)
LLD 1100.00 01-M- 2210-
Gty/State
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aty/State
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City/State
Zip Phone
Zip Phone
Zip Phone
Are you paying taxes here or by report? ❑ Here ❑ Report
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? Nesidential ❑ Commercial
If residential, is it: ❑ 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? t] Yes ❑ No If Yes, you may need to contact Historic Prreservat/on
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you wi/l need an asbestos assessment to submit with this appIcabon.
Description of work
kq:
*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 d'
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: signature 'O► Date
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