HomeMy WebLinkAbout624 SMITH ST - APPLICATIONS - 10/24/2012Fort 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 ❑ Gas 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 appliicQcable information on the application. Incomplete applications will not be accepted.
Application # F3IC20 &sso Date
For ofce use only
Job Site Address (required) rValue of Construction (labor, materials, profit)
in-zSrn :i�, S�. (vDa
Property Owner Name
Address
City/State
Zip
Phone
.0A Jgn6e n
� 20 Sm i �
Sk . ±—ac i l-o(I,,, s
CD 8
97b-ZZ,7-Fw
Applicant Name
Address
City/State
Zip
Phone
8 4-k Jci1eye
624 SM ,+L
S-E Fa. &I
(o $OS
976 ZZZBd/2
Contractor Lic #
Address
City/State
Zip
Phone
//
hOMc�J �'JOMcaf
�� /�� l9U/�ox��
d'oS-2Z
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here
or by report? ❑ Here
❑ Report .
Sales tax number isrequired byall mntractom
Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or commercial project? Ekesidential ❑ Commercial
If residential, is it: ❑ 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? 01 Yes ❑ No If yes, you mayneed to contact Historic Preservation Jc511WU')
If this is for a demolition permit, what year was the building constructed? Be{�_ lq75 "e`j
if prior to 1975, you will need an asbestos assessment to submit with this application.
of work `i , met"A�
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the company name or Gty 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.
Print Name: �� JdtnSe � Signature Date 1 D/Z`l of 2