HomeMy WebLinkAbout6802 NIMITZ DR - APPLICATIONS - 10/30/2012 (3)City of
Fort 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) ❑ Gas Lighter K as 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 on the application.
Application # ',) I %-6 ('0!5k�
For office use only
Incomplete applications will not be accepted.
Date 101a)U�2
Job Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name
Address
City/State Zip Phone
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Applicant Name
Address
City/State . Zip Phone
550
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Contractor
Lic #Q"13,)
Address
City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? % Here ❑ Report
sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes No
Is this a residential or commercial project? XI Residential ❑ Commercial
If residential, is it: ❑ k4
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 A No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If pfior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*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 #
Electridan 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: ['�. _ o I e
Print Name: II `[U(� SignatureDate 12