HomeMy WebLinkAbout612 LOUISE LN - APPLICATIONS - 3/11/2013FROM :NCR
FAX NO. :9702299993 Mar. 12 2012 12:06PM P1/2
�-F�ort of
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). 9(Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
L7 Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing Q Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicablee information on the application. Incomplete applications will not be accepted.
Application # Date
For olllee use only
Sob Site Address (requlred)
value of Construction (labor, materials, profit)
2-( 0 --
Property Owner Name Address
City/State Zip
Phone
CID ID
�434
Applicant Name Address
City/State Zip
—D
Phone
Contractor Address
City/State Zip
Phone C1 tb
�� ✓►-�Ctoyu�aA;Y,�rc. �12
Ave. (=t cotl��t5
z3-
_.
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here X' Report
5aiestax numbersrequiZbyall cvabacmts.
Are you paying with your trust account?
%,Yes ❑ No
Is this a residential or c meroal project? Residential ❑Commercial
If residential, Is It: M Single Family DetacKed ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ office ❑ Retail
❑ Restaurant ❑ Other (explal) _
Is this building 50 years of age or more? O Yes f7No If yes, you may need to contact Historic Presemation
If this Is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit w/th this application.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: stthe company name or City of Ft ccllins license. #
Electrtdan At( umber___ Medianlcal 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; ' I n
Print Nam 1 Ytp� l t —LSig ,VS t� Date `" LI ��