HomeMy WebLinkAbout419 DERRY DR - APPLICATIONS - 9/23/2011109/23/2011 14:50 9703305645
of
Flirt Cothns
SLAUGHTER ROOFING
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
PAGE 06/07
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 ❑ Lawn Sprinkler ❑ Mobile Home replacement 0 Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater 0 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 #F31101:��
Date %3_�L
For ofice use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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-7
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000 1
Property Owner Name Address
Gty/States Zip Phone
Ci Co gosis RMC110-1w
Applicant Name Address
City/State Zip Phone
Contractor Address
City/State Zip Phone
aSIO C
t)9i: 0
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? )k( Here ❑ Report
Sal mynumbar isrequtmdbyancontractom
Are you paying with your trust account? 01 Yes ❑ No
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Is this a residential or commercial project? 0 Residential ❑ Commercial
If residential, is it: IX Single Family Detached 0 Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank 0 Bar la Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant 0 Other (explain)
Is this building 5o years of age or more? 0.Yes )a No If yes, you may need to contact Hlsmnc Preservation
If this is for a demolition permit, what year was the building constructed?
If pffor to 1975, you will need an asbestos assessment to submit with this appl/cadon.
Description of work
*If lawn sprinkler/backflow preventer,, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Ust the company name or Cry off! Collins license #
Sectridan Plumber Mechanlcal Roofer Other
I Hereby acknowledge that I have read this apprication 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
Date ___T_ 2.3 111_