HomeMy WebLinkAbout6719 HOLYOKE CT - APPLICATIONS - 10/7/2011Planning, Development & Transportation
City of 281 N. College Ave P.O. Box 580
!1� 0�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 ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, mo I and6fT�
manufacturer). C�v
Complete all applicable information on the application. Incomplete applications will not be accepte .
Application # I (L5oDate rla lfo �. /
For office use only
Job Site Address (required)
PIN - A -, YS L'\ Q W
Value of Construction (labor, materials, profit)
Property Owner Name
Address
City/State Zip
Phone
Ai\pro q. Pr',.1
C-11`%
A-bi ok� CN_ F Co W151LS
Applicant Name
Address
City/State Zip
Phone
Contractor Lic #
Address
City/State Zip
Phone
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5'704 N, crc-3 F 8Us2y
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Contractor City of Ft. Collins Sales Tax
#
Are you p ying taxes here or by report?
❑ Here 4;( Report
5alestax number isrequired byall contractors.
44LSZ
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or commercial project? -0 Residential ❑ Commercial
If residential, is it: l2fSingle Family Detached ❑ Condo/townhome (single family attached) ❑ 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 may need to contact Historic Preservation
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 with this application.
Description of work aim_ si.,. ��� ►,� 3CcKJ 9 F � ti MOLA24�3 L<J,�4 so
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Su bco ntra cto rs: List the company name or City of Ft Collins license #
Electrician 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.
Applicant:
Print Name: �� Signature �` Date 9 D- 7- //