HomeMy WebLinkAbout620 Agate Ct - Applications/Water Heater - 05/28/2019Cltyof 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 9 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 # W6&as ® Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
62-0 ale, a �- cotw.s (so 8 C) $ 1 1 q11 .3-7
Property Owner Name Address City/State Zip Phone
Stet e. Su6 20 NqAL C* . Fork gglk lS cos M-?'5 Cho . 22'1- -1111
Applicant Name Address City/State Zip Phone
McJirla4 1,ir- 1904 S wM yx 0r%-L+ p, torqmoMCO 8bSNA T2D Z458123
Contractor Address City/S ate Zip Phone
r umVLrN Me l8oS 'Dv Qry k C!o �4 Z� � ?t2
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number isrequired byallcontractors. Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? N Residential ❑ Commercial
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 ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work 1 O-Arer ka-3,0r IfAA _ Q Ercio-e, eV54iD?5 V-p-Sew �,0cje'x—
ard- Y'zk:Y Co' UA to ne-to u� . $ear'
PJew wWr Wta y- dksc.�on% 50 Mi/Co QA1 Gas-T Rlreem E S kc)13
*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 ofFt Collins license #
'fir 0MIP
Electrician PlumberW� C 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:lili&Ue.1 GE4_ , Signature Date
Revision date 2/6/2017
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