HomeMy WebLinkAbout6570 Portner Rd - Applications/Backflow - 08/03/2018City of Planning, Development, & Transportation Services
Fort 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 ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation XWater Heater Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applica llq informatio on the application. Incomplete applications will not be accepted.
Application # ��� Date
For office use only
Job Site Address (required) Val of Construction (labor, materials, profit)
-1 �I d � a
to m'r v 10 5 5 5 eah
Property OwnerNamet Address City/State Zip Phone
CG OC CA\I� ()S Po �DX StO Ft (.!IFo3 JOS2
(� 1
Applicant Name Address City/State Zip Phone
10( � (441;r' �Sa Tlaaa k 010
,
Contractor Address City/State Zip Phone
S a rY• e�
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here Report
Sales tax number isrequired byall contractors. Are you paying with your trust account? ❑ Yes No
39
Is this a residential or commercial project? ❑ Residential XCommercial
If residential, is it: ❑ 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 .4 Other (explain) CCt it (K)"i c,41
Is this building 50 years of age or more? ❑ YestN(No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work n (� t(C VJFA'+e Ck -c(-s 0 (6,
n r�
c e
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must lisx license r,'ici�7/
�O 110
Subcontractors: List the company name or City of Ft Collins license #
Electrician i Plumbero) P- y S 1 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: .Y1r�\uln,1 I 1
Print Name: , ' \\J Signaturewl �J V Date V I
U v
Revision date 2/6/2017
0d0
4a