HomeMy WebLinkAbout5402 Copernicus Dr - Applications/Furnace - 03/27/2019(_ i-i:y'L l
This application is
❑ Demolition (intern
XNeating Unit ❑ 1
❑ Ventilation ❑ W,
manufacturer).
Complete all appllc
Application #
For of
Job Site Address (re
VU
Pro erty Owner Name
k�ThqI -raV
Applicant Name
Contractor
Contractor City of Ft. 0
SAes taAr ymAr is required
is this a residential or cc
If residential, is i�
❑1
If commercial, is it: ❑ I
❑I
Is this building So years
If this is for a demolitio
If prior to 1975, you wi// ,
Description of work
*If lawn sprinkler/backflow
Subcontractor Id'stthe
Electrician-
1 hereby acknowledge that I
comply with all requirement!.
permit is not valid until ft
Applicant:
Print Nam
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
FER-THE-COUNTER PERMITS ONLY
used to apply for the following permits only (check all that apply). ❑ Air Conditioning
i-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
Dater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
nformation on the application. Incomplete applications will not be accepted.
19 01 �/3;�_ Date �-7 l 9 se only
XMUSUrr yU625 Value of Construction (labor, materials, prof t)�
wKnc" -b-,/- Fwnttns =� ':7 D111VW
Qd^dre�nn� nAI^ City/State Zip O Phone
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Address City/State
n e_ ! ZIP Phone
Address v City/StateZipv t
11. Phone
r .. • • j ' die f�w` : li _�0� 1 ��t'l�L(� � �1{.WI� C/ti Ot;`%7u(4%� !}�j�'!
Sales Tax # Are you paying taxes here or by report? ❑ Here
contractors Are you paying with your trust account? yes ElNoport
rciai project? F Residential ❑ Commercial
e Family Detached- ED Condo/townhome (single family attached) ❑ Duplex
amily (apartment) ❑ Garage
Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
irant ❑ Other (ex glain) _
g e or more? ❑ 1� $NO If yes, You i to contact H/stor/ ion
mit, what year was the building constructed?
an asbestos assessment to submit with this appl%ation,
r, must list licensed plumber. If first-time A/c, must list licensed electrician,
name or City of Ft Collins license e
Mechanical_•_ Roofer
Other
read this application and state that the above information is complete and correct. I agree to
Dined herein and city ordinances and state laws regulating building construction. I know that a
been paid and issued.
natu
DateW f I