HomeMy WebLinkAbout623 LESSER DR - APPLICATIONS - 11/15/2012City O Planning, Development & Transportation
Fortor N. College Ave P.O. Box 580
Collins.7 Fort Collins, CO80524
Phone 970-416-27402740 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 Uriit ❑ Lawn Sprinkler ❑ Mobile Home replacement fi400fing ❑ 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 # S lloG � l�-1
For offlce use only
Incomplete applications will not be accepted.
Date 11\ 1xb� )'Z-
Job Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone 33�
�X 1 \-1
L v C`1 Z 30 - ZZ
Applicant Name Address
City/State Zip
Phone
tic # 1k-1-1�3 Address
City/State Zip
Phone q-10
pContractor_ y.,
caber a e a58 S. L\
UuNc Co ;50t0
22-A-\Z00
Contractor City of FL Collins Sales Tax # q \ 3—l(..p
Are you paying taxes here or by report? ❑ Here
it Report
sales tax number&requiredbyall contradom
Are you paying with your trust account? gYes
❑ No
Is this a residential or commercial project? ® Residential ❑ Commercial
If residential, is it: 0 Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotei/Motel ❑ Medical office ❑ office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑Yes ❑ No If yes, you may need to cnntactHistoric Pfeservabon
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you wi// need an asbestos assessment to submit witfi ffiis application.
Description of work
, . ,.
NQ
a .f - \ U
*If lawn sprinkler/baddlow preventer, must list licensed plumber.. If first-time A/c, must list licensed el clan.
Subcontractors: List the company name or Crty of Ft Collins license # '(Y UN\ -`1 0.
Electrician Plumber.
Mechanical Roofer -\1 e D 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: Signature'Ll Date
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