HomeMy WebLinkAbout609 JANSEN DR - APPLICATIONS - 9/13/2011C.it of - .., — - _ .
281 N. College Ave P.O. Box 580
Fort Collins
Fort Collins, 2740
Phone 970-41616-2740 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 41�1,00fing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # & Date �1� 11
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property 0 ner Name
Address
City/State Zip Phone
Applicant Name
Address
City/State Zip Phone
Contractor
Address
City/State Zip Phone
2
9IeSfor
• r?- TO f -ZS_0
t: Collins Sales Tax #
Contractor City of Ft-.'Collins'
Are you paying taxes here or by report? PO Here ❑ Report
Sales tax number is required byall contractors .
Are you paying with your trust account? P9 Yes ❑ No
S-ri 0 50
Is this a residential or commercial project? esidential ❑ Commercial
If residential, is it: mgle Family Detached\` ❑ Condo/townhome (single family attached) ❑ Duplex
Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other(explain
Is this building 50 years of age or more? ❑ Yes o 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 work C)ue �"isi-ir Mc terra s -M. iHe A?"'ne nvj rerc;a4- wi-WiZL - ci e5 0
&Gti IN
at '01Q nticr,- Insi-e,llVey-,V\ �ah 0:"J rec a•1i-icta ons.
*If lawn sprinkler/backflow preventer, must list licensed p umber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
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 la s regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicanti%�
Print Name: ���Pi �(2r�c�S Signature Date 13
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