HomeMy WebLinkAbout636 BLUE MOUNTAIN DR - APPLICATIONS - 9/15/2011FCi#yof 281 N. Go11ege Ave P.O. Bmc 580
drt Wns FortCollirrs, CO 10524
1 Phone 970416-2740 Fax 224.6134
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OVER-THE-COUMMR PERMITS ONLY
This applicetlon Wit* be used to apply ow the following permIte only (check all that ap*). 0 Air Conditioning
P Demolition "nor non- nal) O ElecMeal Allandion (not servioe change) 0 Gas Lighter 0 Gas Log
13 Hating Unit Q Lawn Sprinkler O'Mobile Horne replacement Q Roofing 0 Sewer Line 0 Phoio-vatteic
Ventilation b Water Heater -13 Water Line 0 VftdlPeM StDV0 (must be EPA certified, provide make; modetand
mete all applicable Inf6miatIon on the application. Incomplete application wignot be accepted.
4puaildon # �'� fete
Job S'ibe.l4adr (rra red) Jahn of Consbvetlon (labor,159ft prom .
131 M for . 1
{Property Oww Name Address M/�e zip tee.
a s r
cant NamJAddress city/state Co n-pp Ptx=
0 C'U
'ContrxborJ Address dtymate ZIP Phone`
City of FL Collins Sales Tax If Are you paying t Dm here or by report?)2QHere Ci Report
Wivan&er4iept dbya9 Are you paying with your trtja: account? Yes D No
this a resderM or amm dal prvJecCt&rtial 0
nily GmmwcW
residential, is it: Vtngie Fa Dewed 13Como/wwnhome (angle family atlade M 13 DuplesC.
Muffmity (aperbnent) 0 Garage
omnerdal, is it a Barak Q.Bar 0 Church D How/mobd Cl Meckal office O Office 13 Retail
13 Restaurant 0 Other (explain)
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this balding 5o Years of age. or rrmre? 0 Yes 0 No lfyps, yvu may need igewaztmb *
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this is fora den oMm permit: what year was {fie building owed?
,Pyor W . y yw W%fviledm7 BStrf asawrrerity t WO 4POCafta
eecrl� on of�� 11 �i' __,� 1 �vl i/ . Ci6Y O 12
lawn sprirrtdef/baddiow preventer, nvi t He licensed plumber. If first -fine A/4 must net Hmmd ekxbmm
=*= msr LW Me crtmWa►yname or Cry OR C2Dv ffcwm 3f
own Plumber - - Medal - - PA fer ' _OUW.
fj hmby aao,mviedae that I hm read #aft appiicaft and state that the above' information is =npiete and aorl+ecG r agree to
corn* with as aquiremsts cx taiefl herein and c4 ordlnaraes anf state laws reguNm building aw2mcdon. I_imow.that a
penrrR is trot valid u ntll it has been paid and Issued. E
j Print AYYW
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