HomeMy WebLinkAbout410 N COLLEGE AVE - APPLICATIONS - 9/16/201309/16/2013 16:40 FAX
Ica 001
City of
F„` rt Collins
Planning, Development dtt Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970416-2740 Fax 224-6134
OVEWTHE-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 Alteratlon (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ bile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ZMater Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and a�
manufacturer). ��V
Complete all applicable information on the application. Incomplete applications will not be accepted•
Application # _1613Q Cia?F _ Date
&r offln- um only
lob Site Address (mquira4dd
Value Of C ristruction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone5�6—
c -�/io s✓
r Lq
q'a1-31�
Applicant Name Address
Pto Hericid1j;eil "1yq �, .i,~iriccy 11'A3.-(q?
city/state Zip
Fr. (►c(j�r,s,C�. $L�S��j
Phone
91t-+43--3cl-3r
Contractor L I c_ I IT, ryl P - `31 c? Address
city/state Zip
Phone
Nfe�r-illEr,1 Loloor -D D`� 7yq S I.>°r)tQt 44K: -I42
Ft. eojliA� C� z" -)jq
97v.-,gI-h87a-
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report?
)� Here ❑ Report
Sales tax number is requhrd by 0 conbachxx Are you paying with your trust account?
❑ Yes X No
Is this a residential or commercial project? ❑ Residential P'Commerclal
If residential, Is It: ❑ Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is It: ❑ Hank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office 0 Office 0 Retail
13 Restaurant ❑ Odw (explain)
Is this building 50 years of age or more? O Yes ONO ffyh�, you may need to contact HlstiaMc HhaserveVon
If this Is for a demolition permit, what year was the building constructed?
0pr1or Iv 1975, you will need an asbestos assessment to submit wlth this appllcapon.
*If lawn sprinlder/baddlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician
Subcontractors: L&t the company name or Oty Off? Cpldns license # � ' r -
%—t 8-13
Oedndan 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: fib �l✓R'r 1 f IC } l signature Date