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HomeMy WebLinkAbout4454 HOLLYHOCK ST - APPLICATIONS - 12/9/2011DEC-10-2011 15:48 From:Allen Service City of ��.Fort Collins 970 484 4448 To:92246134 Pa9e:6,9 Planning, Development & Transportation 281 N. College Ave P.O. Box SSo 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) O Electrical Alteration (not service change) © Gas Lighter ❑ Gas Log Heating Unit O Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line O Photo -voltaic ❑ Ventilation ❑ Water Heater ❑ Water Line C3 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 #_ f2l' 1 1 1 l- l For orfrce use only Date JA- 0'—a Job Slte Address (required) 1-1-L117 �� Value of Construction (labor, materials, profit) 1)h /Ji, I M ("gS74 do d'o5a a�-J-7- Property Owner N me ess1 kippm Address City/State Zip Phone �J 5010 qo-(P q 79 Applicant Name Address City/State Zip Phone Contractor Address City/State Zp Phone O Co vo5-Q4741- qS 1 Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here XReport Sales tux number /s required by air coatracwm Are you paying with your trust account? )( Yes O No Is this a residential or commercial project? Alkesidential ❑ Commercial If residential, Is it; Single Family Oetach d ❑ Condo/townhome (single family attached) : 0 Duplex O Multifamily (apartment) 0 Garage if commercial, is it; O Bank ❑ Bar 0 Church ❑ Hotel/Motel ❑ Medical office O Office 0 Retail O Restaurant ❑ Other (explain) Is this building 50 years of age or more? 13Yes ❑ No If yes, you may need to contact Histo dcVreservation 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 *If lawn sprinkler/backtlow preventer, must list licensed plumber. If first-time NC, must list licensed electrician. Subcontractors: Ust the company name or City of Ft Col/ins license o 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: Print Name: Signatur DataLa q i�