HomeMy WebLinkAbout4142 MOSS CREEK DR - APPLICATIONS - 7/29/2011FROM :NCR
FAX NO. :9702299983 Jul. 29 2011 02:00PM P1/1
City Of Planning, Development & Transportation
281 N. College Ave P.O. Box S80
Fort Collins 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 CI 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 applicable information on the application. Incomplete applications will not be accepted.
Application # Ri 65-� � Date
For_Ace use only
Job Site Address (requ/red)
Value of Construction (labor, materials, profit)
v J00
Property Owner Name
Address Zip
Phone
/1Clt�y�/Sttattee
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Applicant Na a
Address City/State Zip
Phone
S V4
Contractor
Address City/State Zip
Phone CF-M
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here
XReport
Sales tax number Isrequlredby0can tracMrs
Are you paying with your trust account? P(Yes
13 No
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Is this a residential or commercial project? V Residential ❑ Commercial
If residential, is it: Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
KMultifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes 36No If yes, you may need to contact hlistoric PreServatiOn
If this Is for a demolition permit, what year was the building constructed?
Ifpnior to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backFlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List/the company name or City of Ft Collins license ¢
Electridan f�V �d .9,GC. 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.
Appli4
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