HomeMy WebLinkAbout5245 Cornerstone Dr - Applications/Furnace - 02/16/2017City of Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
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. Incomplete applications will not be accepted.
Application # & I tl o r%-t Date a I LP / as 17
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
50-"') 17\r-- 61'�s 5!�).
Property Owner Name Address City/State Zip Phone
eAwctir 4 FA. &)52g -1
Applicant Name Address City/State Zip Phone
'�t nA 2-00 2:2-r,yeny-PALdCo goU 70- w Z3
Contractor a PA /� Address City/State Zip Phone
e • n Co A- lC k � 11-76 3 -0315
Contractor City of Ft. Collins Sales Tax Are you paying taxes here or by report? XHere ❑ Report
sales tax number is required by all con&actors. Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? .K Residential ❑ Commercial
If residential, is it: KSingle 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 ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work F! rr\cacp. IRv c)\Ckr 4 rn D
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
subcontractors: List the company name or Gty of Ft Collins license
Ae # I
Electrician Plumber Mechanical/t�Z t1(a�\Iy\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: 1, g�—
Print Name: J )P rQ K- xu si nature 11n n 4 Date I llY 2D I
Revision date 2/62017