HomeMy WebLinkAbout337 Derry Dr - Applications/Furnace - 08/08/2019P�itjC®lll�s Planning, Development, & Transportation Services
r 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). X Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
g 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 on the application. Incomplete applications will not be accepted.
Application # 1 %�� L � Date _ 21911 q
For office use only (1�2, 1 L, T l _
Job Site Address (required) Value of Construction (labor, materials, profit)
00 , SO
Property Owner ame Address City/State Zip Phone
3 WAS O-4 - 410
Applicant Na a ddress City/State Zip Phone
Contractor Address City/State Zip Phone
a n
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here ❑ Report
Sales taxnumber isrequired byall contractors, Are you paying with your trust account? Yes ❑ No
Is this a residential o,,rpmmercial project? Residential ❑ Commercial
If is it:
residential, Single Family Detac ed ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamlly (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 A No Ifyes, you mayneed to contact Historic preservation
If this is for a demolition permit, what year wash building constructed?
Description of work . Fjwflaa Ova ale., 01JOIL-MaeftE_
*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: u nOnnnn 0 p W�
Print Name: 11 I111� It Il. Signatu Date
Revision date 216/2017