HomeMy WebLinkAbout420 Tedmon Dr - Applications/Reroof - 07/23/2018122 --11
City of Planning, Development, & Transportation Services
F�rt Collins 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 K 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.
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Application # V t "e L�J Date
Gnu nR a uco nnly
]ob Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner'Name Address City/State Zip Phone
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Applicant Name Address City/State Zip Phone
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Contractor Address City/State Zip Phone
S2vrne OcaAVIeIr Vcrkin4 3n045, Lolkcge- tit '+ta.0 n,rk tuil;n5, c o S a-,o-zz� uas
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? E3�Here ❑ Report
saAss tax number isrequiredbyall mnoacmrs. Are you paying with your trust account? ❑ Yes qNo
2Ll?212-U151
Is this a residential or commercial project? El Residential ❑ Commercial
If residential, is it: 4 Single Family Detached ❑ Cando/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 gNo If ye& you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Desc Iption of work CV4 7-5 Off- s- bllvld f V >taC� w Z i
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List tke company name or City of Ft Collin license #
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Electrician Plumber Mechanical Roofer V 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: CuWI Ul'LW Z 1 I Lv� Signature.(/�Y.Gt�. Cj �t { fi1 ` "7 `(%'1 e5
Print Name: Date
P"Wn Date ZWQ17