HomeMy WebLinkAbout627 SEDGWICK DR - APPLICATIONS - 10/3/2011Planning, Development &Transportation
City Of 281 N. College Ave P.O. Box 580
ort c -0-111 .q 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): 0 Air Conditioning
O Demolition (interior non-structural) 0 Electrical Alteration (not service change) 0 Gas Lighter ❑ Gas Log
0 Heating Unit 0 Lawn Sprinkler ❑ Mobile Home replacement ARoofing 0 Sewer Line ❑ Photo -voltaic
0 Ventilation ❑ Water Heater 0 Water Line O Wood/ Peilet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information. on the application. Incomplete applications will not be accepted.
Application # . - _t?ok W _ Date �k
Pp For office use only
lob Site Address (required)
Value of Construction (labor, materials, profit)
- -
-
Property Owner Name Address
City/State. Zip
Phone
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Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State. Zip
Phone
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10-✓C221 63
G5-0390
Contractor City of PL Collins Sales Tax #
Are you paying taxes here or by report? Pi Here
0 -Report
Sales tax number is required. by all contractors.
Are you paying withyour trust account? 0 Yes
K No
Is this a residential or commercial project? JK Residential O Commercial
If residential, is it: MSingle Family Detached , 0 Condo/townhome (single family attached) 0 Duplex
0 Multifamily (apartment) D Garage
If commercial, is it: 0 Bank 0 Bar 0 Church 0 Hotel/Motel 0 Medical office 0 Office 0 Retail
0 Restaurant Cl Other (explain)
Is this building 50 yearn of age or more? 0 Yes )4 No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of
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*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 license #
Elecbidan 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 s; not valid until it has been paid and issued.
Applicant:
Print Name: 6f C- Signature s-- Date Ig osk