HomeMy WebLinkAbout860 E Stuart St - Applications/Gas - Log, Line, Pipe - 04/05/2018ZOV3
City of
�F6rt Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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This application is to be used to apply for the following permits only (check all that apply). 0 Air Conditioning
0 Demolition (interior non-structural) 0 Electrical Alteration (not service change) 0 Gas Lighter,) Gas LoTFi',-eyaI4,e -
0 Heating Unit 0 Lawn Sprinkler 0 Mobile Home replacement 0 Roofing 0 Sewer Line 0 Photo -voltaic
0 Ventilation 0 Water Heater 0 Water Line 0 Wood/Pellet Stove (must be EPA certified, provide make, mode) and
manufacturer).
Complete all applicable
D information on the application. Incomplete applications will not be accepted.
Application #l W 2So) 4 Date LS
For ofce use only r�-
Job Site Address (required)
Vaallue of Construction (labor, materials, profit)
6-0
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Property Owner Name
Address City/State Zip
Phoneq*9el -
Vm t Ilea
rTG Ke�S S_
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Applicant Name
Address City/State Zip
Phone
Re DIc�S 533a
5-Tiinl-Llc. � T6 i VY
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Contractor
Address City/State Zip
Phone "-/"21,
F - ao
-Fin) 6ee-1ne Pd r4
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?A
Here 0 Report
sales tax numbgris e_qu��40contractom
Are you paying with your trust account? 0
Yes KNo
Is -this a residential
If residential, is it:
If commercial, is it:
or commercial project? X Residential 0 Commercial
,Single Family Detached 0 Condo/townhome (single family attached) 0 Duplex
0 Multifamily (apartment) 0 Garage
0 Bank 0 Bar 0 Church 0 Hotel/Motel 0 Medical office 0 Office 0 Retail
0 Restaurant 0 Other (explain)
Is this building 50 years of age or more? 0 Yes �?" No If yes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
IV"
*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 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: -�f Y✓
Print Names ).%6% I � � Signature
Datet/�
Y.:2-