HomeMy WebLinkAbout1219 Cliffrose Ct - Applications/Gas - Log, Line, Pipe - 07/02/2019City of Planning, Development, & Transportation Services
Flirt Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fare 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 /GPGas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilat'ion ❑ 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 # f H 0 ` Z45'
For office use only f
Date%a l gy 0 ('03W
fn-A�'cCR)
Job Site Address (required) Value of Construction (labor, materials, profit)
12 0 CI
Property Owner Name Address City/State Zip Phone
r,.reioAY\ , I^ust 1712 CIA, C-1- >'' x)1 CJ 805,�5 q-7n 4291 u.
Applicant Name Address City/State Zip Phone
A Cleafl SweazzeL 1la da,,ai &39 W Zsf C1.7() &&V 97a-33 -9'
Contractor / Address City/State Zip Phone
onr/u 'n3 b o �r�`. o.%r, i d tS'riW 4 7fA -3,59-ci In
Contractor City of Ft. Collins Sales Tax #ppooLsas I Are you paying taxes here or by report? ❑ Here Report
Sales tax number is required bya#onnbactom Are you paying with your trust account? P Yes ❑ No
+-cr—•n P-!? a%7 4.r'L.G{ I �OO O
Is this a residential cicommercial project? )E Residential ❑ Commercial
If residential, is it: Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
0❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (expla�p)
Is this building 5o 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 wagthe building constructed?
Description of work Repn)Ve Z .Pur5- ; no O s'/-W-ve-nk A Y-J. ir.54-01 tin u� S
9-'treolap�S i S G Yl Ctr\a A,ruIr� r\ 4fn ea,l rl An n1i,or i`; c %)nrn�nr._
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*If lawn sprinklerlbackflow preventer, "ust list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: list the companyname or City of 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.
A licant:____1�1Srt 04;1-kj'.'IN
Print Name: 9. C' leo.ri ..4cf w vi) /.I_(_'_ Signa`iy re i/ Date r
r
RevWon date 2WO17