HomeMy WebLinkAbout4318 New Bedford Dr - Applications/Water Heater - 03/23/20196Fcityof Planning, Development, & Transportation Services
rt'Co 11h'S 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 Uniit, 0 Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilations 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 # 91 � b a�;&
For office use only
Date E'0�3W
Job Site Address (required)( Value of Construction (labor, materials, profit)
Property Owner Name Address City/State Zip Phone
ENIM3f �S- VL1Pko 0 n . MaS 970-9t74791
Ap 11cant Name Address City/State Zip Phone
�1a3o 'l 8`D�Y �Cl�-2�s�o5
�ntractor _ Address _ City/State Zip Phone
c rnad� ya3oG Tf6- 11M 0o
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here ❑ Report
&Aestax number isrequlredbyall mntractws Are you paying with your trust account? Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: mgle Family Deta ed ❑ 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 ❑ No Ifyes, you mayneed to mntactHistoric Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work _Uoil QU(110 A A 04 Q(k h0 �� Lofcf ,S(�A cell
*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 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:
Print Name: 11 r7 Signature Date 2-
Revision date 2WO17