HomeMy WebLinkAbout919 QUEENS CT - APPLICATIONS - 10/17/201110/17/2011 14:21 9702329739
aiy, cyf
o t Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box S80
Fort Collins, CO 80524
Phone 970-416-2740 Fax 22+6134
OVER-THE-COUNTER PERMITS ONLY
PAGE 02/02
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 El Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation lK 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 # B%% 0q 1 q 4 Date 10 - 1-71 1 I
For office use only
lob Site Address (inquired
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Value of Construction (labor, materials, profit)
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City/StateZip Phone �q I
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Applicant Name Address
city/State Zip Phone q10—
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Contractor Address
city/State Zip Phone Lo%-
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4165 Ibm-i w AIA I Lo N 81Q5 51
Contractor City of R. Collins Sales Tax #
0 Are'you paying taxes here or by report? ❑ Here U Report ,
Sales taxnumberisrequnedby0conbadOK.
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Are you paying with your trust account? 1A Yes ❑ No
Is this a residential or commercial project? §bResidential ❑ Commercial
If residential, is it: Single Family Detachdd ❑ Condo/townhome (single family attached) ❑ Duplex
Multifamily (apartment) ❑ Garage
If commercial, Is it:. ❑ Bank ❑ Bar Cl Church ❑ Hotel/Motel ❑ Medical office ❑ office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 yeers of age or more? ❑ Yes ❑ No If yes, you mayneed to cantactfi#&0fic presemadon
If this is for a demolition permit, what year was the building constructed?
Ifprfor to 1975, you wi//need an asbestos assessment to submit w/Lh Lhlsapplication.
Description of work
*If lawn sprinkler/baddiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List /lie company name or 0Yy of Fe Col/Ins //tense 0
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: n
Print Name�a-►'r Pau Mks✓ _ Signature
Date 10 • 11. 1 1
5
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