HomeMy WebLinkAbout810 E MYRTLE ST - APPLICATIONS - 10/14/2011Fort Collins
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). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater 113"Nlater 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 # �6 11 p!I [)� Date /a -/z/ //
For office use only �i f
Job Site Address (required) I Value of Construction (labor, materials, profit)
f?l () Ir--A4 —r $ //�.��r 0 0
Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
City/State Zip
Phone
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Contractor Lic # Address
City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
OrHere ❑ Report
Sales tax number is required by all conlractom
Are you paying with your trust account?
❑ Yes 53-No
Is this a residential or commercial project? WResidential ❑ Commercial
If residential, is it: mingle 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 SO years of age or more? 5YYes ❑ 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 work i?r' Ac.4CZ-_� 6,.41,UAA%J SE AVJC-C— WIZAI AICLV AZEX uti�
*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 #
Electrician Plumber MP,y3g 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:
Print Name: jMARK DAU&AAAL Signature
Date /Q —7/