HomeMy WebLinkAbout4339 WESTBROOKE DR - APPLICATIONS - 10/3/2013Fort Collins
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
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, model and
manufacturer).
Complete all appl!cable.! nformation on the application. Incomplete applications will not be accepted.
Application # S 3 Date
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip Phone
" /G 11S/—
Z2,5- 99
Applicant Name Address
City/State Zip Phone
Contractor Address
City/State Zip Phone
c 2-AR Co -
(LC- 0 652 q9 a ' y y' 552
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here Report
sales taxnumbe^ri/srequiredbysllwntractnrs:
Are you paying with your trust account? Yes ❑ No
Is this a residential or commercial project? . XResidentlal ❑ Commercial
If residential, is it: `j� Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
/� Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
0 Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes X No Ifyes, youmayneed to contact HistoricPreseruation
If this is for a demolition permit, what year waste building constructed?
Ifprior to 1975, you w111 need an asbestos assessment to submit with this application.
Description of work p�-
*If lawn sprinkler/backFlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins Acerise 0,
Electridan 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: l/
Print Name: 1 ,1/
/E Signature Q
Date
S