HomeMy WebLinkAbout731 Blue Mesa Ave - Applications/Furnace - 03/02/2017Planning, Development & Transportatlon
(.I t y of � 281 N. College Ave . P.O. Box 580
y� ort Collins Fart Collins, 00 80524
Phone 015-416-2740 Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following petinits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Aiteration (not service change) ❑ Gas Lighter ❑ Gas Log
B<adng Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo-voltalc
❑ Ventilation ❑ Water Heater ❑ Water Une ❑ Wdod/Pellet Stove (must be EPA certified, provide make, modal and
manufacturer).
Complete all applicable Information on the application. Incomplete applications will not be accepted.
Application #ol Date
Forofl9ce rota' only
Job Site Address (requLed).
Value of Conshvdion (labor, materials, profit)
�"
-3 lti� I�t sf`
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�co 05z
. 0(T
Property owner Name ( 1
Address City/State ZJp
Phone _
pllpnt Nam
Add , ,
City/State Zip
Phone
Contractor
Address
City/State Zip
Phone
AR Apten
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑Here ' Report
;2i1str.%numbdr/siequhedbyal%am6aabnc
�eA/e
Are you paying with your trust account? Yes ❑ No
Is this a resideiitlal or conrdal projed.? Egl& identtal O Commercial
if residential, is it: Single Family Detached ❑ G.ondo/bownhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) El Garage '
If commercial, Is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building So years. of age or more? ❑ Yes . ❑ No Ifya you mayneed to cantedH/s(prlcPyeservation
If this is for a demolition permik what year was the building constructed?
Ifplfot fn 1975, you will need an asbestos anent to svbm/t WIM 6ils app//radon.
Description of work
*If lawn sprinkler/beddfirst-time
iow preventer, must list licensed plumber. If NC, must list licensed electrician.
Subcontractors: List the company name or O[y offrCb!//ns /loose #
EledTldan 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 constructlon. I know that a
permit is not valid until it has been paid and issued.
Applicant In-1 Y 4tl• � i' �
Print Name—L., �n;i1 �ignatvre. a^ jp