HomeMy WebLinkAbout5109 Country Squire Way - Applications/Furnace - 01/30/2017Planning, Development & Transportation
ON Of 281 N. College Ave P.O, Box 580
.�• j,� I t Collins Fort Collins, CO 80524
Phone 970-416-2740 Fax 22+6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply forthe following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
8<0ng Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing El Sewer Line ❑ Photo -voltaic
❑ Ventilation El Water Heater ❑ Water Line ❑ Wood/PeUet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable Information on the application. Incomplete applications will not be accepted.
Application # Date I " 3 e- - ' I
ForoA9ca Use,only
Sob Site Address (requlrerq.
Value of construction (labor, materials, profit)
SC52 �e
5la C'.ov S f,�
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Property Owner Name
Address
City/State Zip
P one
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A pllcant Nam
up
Address
City/State Zip
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Phone
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Contractor
rAd&e�sS
City/States Zip
Phone
Coiitaactor aty if Ft Collins Sales Tax #
byall :tact:rs.
Are you payln8 taxes here or by report?
Are you paying with your bust account?
❑ Here ' Report
7,yes ❑ No
sal as ta: nun iriz4ulred
�oA U
is this a residential or corrlmerdal project? �Residentiai ❑Commercial
if residential, is it: Ingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartil ent) 13 dangle
If commercial, is It: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 5o years. of age or more? ❑ Yes , ❑ No ifyps, you may need to contact H/storlcPresermblon
If this Is fnr a demolition permit, what year was the building constructed?
If prior to1975, you will need an asbestos assessment to subinit with this application.
Description of work
*If lawn sprinkler/becknow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List tha company name or Qty of Ft Collin 17mnsa #
Elactridan 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. 1 know that a
permit is not valid until it has been paid and issued.
Print Name- , �;l T bt. l!l:Signatura...� �'" " ""'" —"� LY►ie 1- � � _