HomeMy WebLinkAbout3430 Sam Houston Cir - Applications/Water Heater - 04/12/2018PIanning, Development & Transportation
281 N. College Ave P.O. Box 580
qq Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
0VE T Ems' O T IR PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
Dereolition (inteor non-structural) ❑ Electrical Alteration (not service change) ❑Gas Lighter ❑Gas Log
fj (4a- ig Uni Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
CI Ventilation Water Heater ❑Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide mai<e, modzl and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application #_
, roffice use only
Job Site Address (required)
t O
sa, Cs� n C,Yr
pro erty Owner Name Address
�G1Fhn—
Applicant Names,
&
Contractor), Address
Co bit actor City of Ft. Collins Sales Tax #
tst nunberis requiredby all contractors.
IQAF
Date q PA + ! " --
Valve of consorucuon (I D r, tnatei N do
City/State `Zip Phone
City/State Zip Phone
City/State Zip Phone
Are you paying taxes here or by report? ❑ Here •Report
Are you paying with your trust account? )QYes ❑ No
is d-iis a residential or cco}nmerdal project.
sidental ❑ Commercial
if residential, is it: I7&ngle Family Detach d ❑Condo/townhome (single Family attached)
El Duplex
[] Multifamily (apartment) ❑ Garage
it commercial, is it: 0 Restaurant 0 Bar 0 Church ❑ Other (explain)
Hotel/Motel ❑ Medical office ElOffice ❑ Retail
Is this building So years of age or more? ❑ Yes []No Ifyes, you may need to contact Histon/Tpreservavon
If this is For a demolition permit, what year was the building constructed?
hi 1975, you will need an asbestos assessment to submit with this application.
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"`If lawn sprinkler/backilow preventer, must list licensed plumber. If first-time NC, must list licensed electrician.
subcontractors: List the company name OrG'(yofFtCollinslicense 1 OUner
Plumber -
Medianical Roofer
r hereby acknotivledge 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 constnlctlon. I knew that a
permit is not valid until it has beep paid and issued.
Applicant: �y Print Name.,`�--4
a Signature
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