HomeMy WebLinkAbout607 STONEY BROOK RD - APPLICATIONS - 9/28/2012tiqw Sep, 14, 2012 11: 34AM
N.o.5056 P. 2
Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Sox 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 permlts only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter 4 Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line A Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ WoodfPellet Stove (must be EPA certified, provide make, model and
manufacturer),
Complete all applicable Information on the application. Incomplete applications will not be accepted. �\
Application # I ��S �S pate, a -14 --1 a l?S • c)o eoFor office use only U _ J Q, t�e�
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State Zip
Phone
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Applicant Name
Address
City/State Zip
Phone
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Contractor
Address
cy City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax
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Are you paying taxes here or by report? ❑ Here
1:1 Report
Sales tax numberrsrequimdbyaiicontractos.
Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or commercial project? 4MResidentlal ❑ Commercial
If residential, Is It: RSIngle Pamily Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Offlce ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 5o years of age or more? O Yes O No If yes, you may need to mntact fttorlc Presefvatron
If this Is for a demolition permit, what year was the building constructed?
Ifprlor to 1975, you will need an asbestos assessment to submit w1th fhls application.
Description of work
*If lawn sprinkler/backnow preventer, must Ilst licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: to the company name or C Ry of Ft Collins //tense At
Electrldan i Plumber Mechanical I rh �' 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: f�
Print Name: L7 Signature Date q —14 `I�--