HomeMy WebLinkAbout4510 Seaway Cir - Applications/Gas - Log, Line, Pipe - 03/26/2019City
tof c Planning, Development & Transportation
281 N. FOr ` Collins Fort ColCnis, CO 80524 Box 580
Phone 970-416-2740 Fax 224-6134
OVER-THE-COUNTER PEOMITS ONLY aosa
This application is to be used to apply for the following permits only (check all that apply). Air ' nin
Demolition (interior non-structural) Electrical Alteration (not service change) Gas Lighter Gas Log g
C
Heating Unit Lawn Sprinkler Mobile Home replacement Roofing Sewer Line Photo -
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 # N TDI �(`1 " l Date
For office use only
Job Site Address (required) Value of Con truction (labor, materials, profit)
Property Owner Name Address City/State Zip Phone
(�)lnny Ilis-1onl 451D Sec�wayr✓'ts�. CD g052-5 Q7b-Z92,-gz0a
Applicant Name Address City/State Zip Phone
Contractor Address City/State
ZIP Phone
WL_- j`tl__ r't,Gl- sUP19L. ` lL+0& t-tJta,5iDe C>iZ cv 12>0,szC4
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here e rt
Sales tar number is required by all contractors , f) Are you paying with your trust account? Yes No
`T I
Is this a residential or commercia Residential Commercial
If residential, is it: ingle Family Detache Condo/townhome (single family attached) Duplex
u i ami y apa meet) 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 to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this aPPACation,
ption of
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Lislt,the companyname OrCity ofFtCollins license#
Electrician {r0l(eCf IC 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: p
Print Name C laq- � f s% 6 Signature Date
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