HomeMy WebLinkAbout4918 HINSDALE DR - APPLICATIONS - 9/30/2011of
Fort Collins
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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). 0 Air Conditioning
0 Demolition (intedor-non-structural) ❑ Electrical Alteration (not service change)' ❑ Gas Lighter ❑ Gas Log
0 Heating Unit Lawn Sprinkler 0 Mobile Home replacement ❑ Roofing 0 Sewer Line 0 Photo -voltaic
❑ Ventilation Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable(nfo tion on the application. Incomplete applications will not be accepted.
Application # Date 36—aa/�
For office useonly
Job Site Address (required) Value.of Construction (labor, materials, profit)
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Property Owner Name . Address City/State
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Zip
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Phone
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Applicant Name Address
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City/State
Zip
Phone
Contractor Lic # Address
City/State
Zip
Phone
Contractor City of R. Collins Sales Tax #
Sa/es.tax number is requited by a// conbadana
Are you paying taxes here or by report?
Are you paying with. your trust account?
❑ Here ❑ Report
❑ Yes 0 No
Is this a residential or commercial project? 0 Residential ❑ Commercial
If residential, is it: 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
13 Restaurant ❑ Other (explain) _ _ -
Is this building 50 years of age or more? ❑ Yes No If ye.� you may need to confact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbesWs assessment to submit with this app/ication.
Description of work 9A�wi+i
*If lawn sprinider/backRow preventer; must list licensed plumber. If first-time A/C, must list licensed electrician,
Subcontractors: List the company name or Cty of Ft Collins ricer>se #
Electrician 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: A iVMp D —
Print Name; Signature �,�,..Date / �� 01 _