HomeMy WebLinkAbout932 E PITKIN ST - APPLICATIONS - 11/26/201211/26/2012 11:18 FAX
Z 001
City of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
F6rt Collins Fort Collins, CO 80524
`.� Phone 970-416-2740 Fax 224-6134
OVER-THEMCOUNTER 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 Uni wn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation SrWater Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications wlli not be accepted.
Application # eA ao f di,4L4
Date
For oh&e use only
I l l D
Job Site Address rfwuired)
Value of Construction (labor, materials, profit)
roperty Owner Na a Add
L
City/State Zip
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phone 9')0--
a.n 93
Co gas'
Applicant Name Address City/State Zip
for) irl[-L,i=x't t ''uq .t.civxty 4.A3•-lN*7 FT-. 001(+ki5,C0. t���?�{
Phone
�f�� y�I -3` 7�4-
Contractor L It Al P - ' S q Address
Nt r-elvr,i Cn (crade . •749. `a. L1'nlgt
City/State Zip
41A3--fH2
Phone
Ti
Ff. e 163 0D, r:�sQ
7C �i-DS7
Contractor City of Ft Collins Sales Tax #
Are you paying taxes here or by report? X Here ❑ Report
.swestax number isrequredbyall cnnrraetas.
Are you paying with your trust account?
❑ Yes XNo
Is this a residential or wmp erdal project? EMesidential ❑ Commercial
If residential, Is It: USingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, Is It: ❑ Bank 0 Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant 0 Other (explain)
Is this building 30 years of age or more? ❑ Yes ELW If yes, you may need to contact Historic Preservabbn
If this is for a demolition permit; what year was the building constructed?
Ifpnor to 1975, you wll/ need an asbastas assassment to subm/t with b415 applkat/on.
Description of work
*If lawn sprinlder/batkflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Oty of Ft Col/ins %rcrnse 4 -
Eectrician Plumber Mechanical Roofer Q
I hereby acknowledge that I have read this application and state that the above Infom:atlon 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: ��77
Print Name:_PNOYk IkIlElC.:1.is it Signature Xr�� Date.