HomeMy WebLinkAbout612 PROUTY CT - APPLICATIONS - 9/4/201209/04/2012 03:39 3032384051 INTERSTATE ROOFING PAGE 29/34
City- of
Fit Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 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) Cl Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement El Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater El 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 # 53� Date 130
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Navne Address
City/State Zip
Phone
li
5 �/ : 4 co(lirSCU p5
�/a7-
Applicant Name Address
City/State Zip
Phone
le b w.
Co cla_q il 7
-3 8
Contractor Address
City/State .Zip
Phone
4 vef" �
- y
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?C�ere
❑ Report
SalesG7xnumber isrequired by0contractors.
Are you paying with your trust account? ❑ Yes
c-ANo
Is this a residential or commercial project? (4 Residential ❑ Commercial
If residential, is it: ❑ Single Family Detached ':Condo/townhome (single family attached) ❑ Duplex
O Multifamily (apartment) ❑ Garage
If Commercial, is it: ❑ Bank ❑ ear ❑ Church ❑ Hotel/Motel 0 Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes TtGo ,lf yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building Constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
"If lawn sprinkler/backftow 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 1~!$ 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: V MV A U.." Signature ; Date �i z