HomeMy WebLinkAbout1305 Luke St - Applications/Water Heater - 06/28/2018Fort Collins
Planning, Development, & Transportation Services
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 0 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 # b � GAD 0 5OSS Date
For ofl9ce use only
Job Site Address (required) Value of Construction (labor materials profit)13*
1-3055 LoYvp C Ci . Q"M—AL1
Property Owner Name Address City/State Zip Phone
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Applicant Name Address City/State Zip O o 5 L5 Phone q -70
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Contractor Address City/State I,/ Gv Zip 005 2 5 Phone -7 7b
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Contra or City of R Collins Sales Tax # Are you paying taxes here or by report? ❑ Here KReport
Sales tax number isrequlredbya#contractors Are you paying with your trust account? MYes ❑ No
13�
Is this a residential or commercial project? gResidential ❑ Commercial
If residential, is it I&Single 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 iv contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work'n.S ke
*If lawn sprinkler/backflow preventer must list licensed plumber If first time A/C, must list licensed electrician
Subcontractors List the company name or tatty of 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 J
i 0
Print Name 1 W"- l 6 �47 Signature i Date 11
Revision dale 202017