HomeMy WebLinkAbout106 Fishback Ave - Applications/Reroof - 06/10/2019City of Planning, Development, & Transportation Services
F�Ort 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 ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer)..
Complete all applicable information
s on the application. Incomplete applications will not be accepted.
y Application # 1�`�(,Ln Datoo-i - /0 — z0 Ili
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
/66 /C0tl61) Co. /0 ZOD
Property Owner Name - Address i /State{)SZI Zip Phone 303
I All
/1/ �f edl/� 9l 9 `I
Appficant Name Address City/State Zip 9011; (Z ���^ Z!�
L�e-ttll CA 6ellefac 'I
Contractor Address City/State Zip Phone Vo
vorAe-"I C&0-1�A C117 I� Z/I�
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? 111,4ere ❑ Report
Sales tax number isrequired byall contractors Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or c mercial project? 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 may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work 5 Sh /9r o e4IY
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*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: �, , -/J C 7- Ol
Print Name:-�Signature Date r
Revision date 2J6I2017 ^ ^ n f'! a 1 I I