HomeMy WebLinkAbout1020 Rolland Moore Dr - Applications/Water Heater - 01/29/2018C'tvof Planning, Development, & Transportation Services
fort Collins Community Development & Neighborhood Services
281 North College Avenue 970 416 2740
Fort Collins, CO 80524
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 Tom'
I-- 7,1-1 C
Application #_,>) 000 (� ft/ Date
For office use only
Job Site Address (regmred)
Owner Name Address
Applicant Name Address
Daniel Ormesher
Contractor Address
Independent Plumbing Solutions, Inc. 1611 E Li
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by all contractors
45189
Value of Construction (labor, materials, profit)
A /_-7 s'a
City/State
�7
Z Phone q1a �_ 7360
Zip hone
city/State Zip
Ave, Unit A, FC, CO 801
Are you paying taxes here or by report?
Are you paying with your trust account?
Phone
)70-566-1377
❑ Here C91eport
❑ Yes Erlgo
Is this a residential or commercial project? residential ❑ Commercial
If residential, is it: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
O'Multifamily (apartment) ❑ 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 morel ❑ Yes ❑ No If yes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work
*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 #
Electrician Plumber MP610 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: "'rlrmachPr SDate
Print Name ^ �I ignature
Revised 11232016