HomeMy WebLinkAbout636 BLUE MOUNTAIN DR - APPLICATIONS - 1/27/2013City of Planning, Development & Transportation
FQA ` Collins
Ms .281 N. College Ave P.o. sox 580
R 1l 1 Fort Collins, CO 80524
Phone 970-416-2740' Fax 224-6134
OVER-THE=COUNTER PERMITS ONLY
1. 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, 17 Roofing ❑ Sewer Line ❑ photo -voltaic
❑ Ventilation d Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Corrtplets all applicable information on the application, Inceitiplete appiications wilt not ba accepted.
Application #
rbr Office use an/y
Job Site Address,(mqulred)
P rty Owner me Address
P�PCrI�C �asC/ �t,�G�3l���Gi�,
Applicant Name Address
Contractor Address
'�- {-k� �C1Fj . ('.EJ tit N � .. •:. , .
Date 1 a►.rl 2-1 U1
Value of con ctilon.(labormaterials, profit)
Clty/State Zip Phone
City/State
ZIP Phone
Zip Phone
Contractor Cityof'Ft. Collins.SalesTaz.# � vu U'' '—
Sales tax numbei-is rerjulnadbyallcontractors Are you paying taxes here or by report? CI Here ❑ Report
Are you paying with your trust account? ❑ yes ❑ No
Is this a residential oro."menial project? Residential ❑ .Commercial
IF residential, Is it: MSingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
11 Multi�mflY
If commercial, is it: 12 Q nk0 Barp ❑ Church ElHot I/Motel ❑ Medical office 0 Office C] Retail
❑ Restaurant ❑ Other (explain
Is this building 50 years of age.or more? .a yes o Jr yes, you may need to contact H/storicpmservation
If this is for a demolition permit, what year v6s the building constructed?
Ifpr/ar to 1975, You W11 need an asbestos assessment to submit with fhis appllcah'on.
Description of work
*If lawn sprinkler/backfiow preventer, must list licensed plumber_ If first-time A/C, Must list licensed electrician.
Subcontractors: Lst!>yemmpenynameofCltyof)!tGo//ins/lcenseA .
Electrician_ Plumber
-- Me�hanl4l-� Roofer
--� Other
I hereby acknowledge that I have read this applicatieri and state that the above in 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:ha's been paid and issued.
Applicant- ,�
'/
Print Name V �17/(��a1Wa
,i�i9nat7y�F�d
C% Date