HomeMy WebLinkAbout4361 WESTBROOKE CT - APPLICATIONS - 4/18/2013Apr 18 13 10:36a DBR Denver
Fort Collins
Planning, Dev
281 N. College
Fort Collins, CO
Phone 970-416
OVER-THE-COUNTER PERM
3032748601
This application is to be used to apply for the following permits only (check al
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change)
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacementRoofing ❑ S
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA
manufacturer).
Complete all applicable information on the application. Incomplete applicatio
Application # 131 it 19 I Z5 Date
For olfice use only
p.2
Ib7 . 1v
sent & Transportation
P.O. Box 590
Fax 224-6134
ONLY
that apply). ❑ Air Conditioning
Gas Lighter ❑ Gas Log
Ner Line ❑ Photo -voltaic
ertified, provide make, model and
will not be accepted.
Job Site Address (required)
Value of Cor�struct-on
(labor, materials, profit)
-5(o1 ez, 4
f 614 f.
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I1 ()
Pr erty Owner Name
Address
City/State
Zip
Phone
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F
App icant Name
Address
City/State
Zip
Phone
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,,
6-19 N, 4/1-v . 11
/`41'<Jl, n s
976'
Contractor
Ad ress
City/State
Zip
Phone
Contractor City of Ft. Collins Sales Tax
# YLLN %
Are you paying taxes here
or by report? Here
❑ Report
Sages tax number is required by ail contractors.
Are you paying with your t
lust account? ❑ Yes
' No
Is this a residential or commercial project? )KResidentaal ❑ Commercial
If residential, is it: Single Family Detached ❑ Condo/townhome (single family a ched) ❑ 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 }"No If yes, you mayneed to cor/tact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will nod an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/back low preventer, must list licensed plumber. If first-time A/C, must list
Subcontractors: Ust the company name or City of Ft Collins license #
Electrician Plumber Mechanical Roofer
eledridan.
"1 Other
I hereby acknowledge that I have read this application and state that the above Information i� complete and correct. i agree to
comply with all requirements contained herein and city ordinances and state laws regulating b�ilding construction. I know that a
permit is not valid until it has been paid and issued.
Appliorrt: ZA'
Print Name: " �a' /C t rt�r'i SignatureL jJ` f (yG 'Cf:'nate
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