HomeMy WebLinkAbout1704 W Lake St - Applications/Reroof - 02/10/2017Fort Collins
Planning, Development, &
Community Development
281 North College Avenue
Fort Collins, CO 80524
Transportation Services
& Neighborhood Services
970.416.2740
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 Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information
on the application.
Application # 1
� I (J loapj` l
For o ce use only
Incomplete applications will not be accepted.
Date /y - Q 2 ( /
Sob Site Address (requlred) Value of Construction (labor, materials, profit)
37A Val . L &J,e (�b ql.RtC6l /UUS � ( Do
Property Owner Name Address City/State Zip Phone
01 S 1704 b0i .LAO. — r6 91s3DZ,4919
Appllcan Name Address City/State Zip Phone
VD rvlco U�-G IbZ S St Leve" eo 9� DORSEDG'7D
Contractor Address City/State Zip Phone
l�l (►�kJY [02 ' L 10v a1,�- a�7 97009oZ
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here.or by report? $t;klere ❑ Report
Sales tax number is required by allconbactors. Are you paying with your trust account? ;Yes ❑ No
Is this a residential or commercial project? Ac Residential ❑ Commercial
If residential, is it: ® Single Family Detached ❑ Condo/townhome (single family attached) Cl 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? O Yes O No Ifyes, you may need to contact Historic Preservation
If this Is for a demolition permit, what year was the building constructed?
Description of work C 6�:,1 40,c�L�?2 'vo_w L4:-i sl
lac 2.>L
tt t
*If lawn sprinkler/badcFlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List Me company name or Clty of Ft Collins license # \\
Electrician Plumber Mechanical Roofer ZV 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 stat laws regulating building construction. I know that a
permit Is not valid until it has been paid and Issued.
Applicant:
Print Name: P� rndr Signature Date �lU
Revimd W2312016