HomeMy WebLinkAbout904 W Mulberry St - Applications/Furnace - 03/26/2019City of Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services a�.
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.- 281 North College Avenue
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Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
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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 ❑ 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 # f5 f qO 1 47M Date 42
For office use only 010,
Job Site Address (required) Value of Construction (labor materials, profit)
Property Owner Name J Address City/State Zip Phone
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Applicad Name (� Address City/State �rZip \Phone
O �MP I�e�t�N� I�i�O�NNfJ t iR T 1�� IG`�LL��1V (O 0525 (176Wi '19146
Contractor Address City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here isl-Report
Sales taxnumberisrequiredbyallcontractors. Are you paying with your trust account? ❑ Yes 2LNo
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Is this a residential or coqmmercial project? Residential ❑ Commercial
If residential, is it: If 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 �k 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 -7 wp a
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license#
Electrician Plumber Mechanical R— Roofer Other
I hereby acknowledge that 1 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: 11 3 'z
Print Name: ef+iKv� C�6b Signature Date
Revision dale 21612017 G'
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