HomeMy WebLinkAbout621 S WASHINGTON AVE - APPLICATIONS - 9/5/2013City of Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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 fi<qoofing ❑ Sewer Line ❑ Photo-vo(taic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable informin ion on the application. Incomplete applications will not be accepted.
Application # F)00 `C-70 .-)- Date C _s - a
For of re use only
Job Site Address (required) Value of Construction (labor, materials, profit)
2 S �\
Property Owner Name Address
City/State Zip
Phone S33-
j
Q15 -
Applicant Name Address
City/State Tip
Phone
Contractor Lic # 1K 1-1 �� Address
City/State Zip
Phone Ci- 0
Ct-t LSS S • La !'\
1-Tc- CiD
Contractor City of Ft Collins Sales Tax # LAj J~1(,s
Are you paying taxes here or by report? ❑ Here Report
sales tax number is regrmed by aff mntradnrs
Are you paying with your trust account? Jd Yes
❑ No
Is this a residential or commercial project? UPResidential ❑ Commercial
If residential, is it EDSingle Family Detached ❑ Condo/townhome (single family attached) 0 Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant O Other (explain)
Is this building 50 years of age or more? ❑ Yes 14No If yes, you may need to contact -Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you wi// need an asbestos assessment to submit wffi this application.
Description of
.-1 11, -�)q„ a r-es = \ \
*If lawn sprinider/backflow preventer, must fist licensed plumber. If first-time A/C, must list licensed elktncian.
Subcontractors: List the company name or Gty of Ft Collins license
Electrician Plumber Medianical 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 unto it has been paid and issued.
Applicant:
Print Name: ` v Signature '1'Z��' Date ` \ '51
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