HomeMy WebLinkAbout4702 DUSTY SAGE DR - APPLICATIONS - 4/21/201404-23-14;07:56AM; ;970-484-4448 # 12/ 15
City. of
ortiCoLtins
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
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) 0 Gas Lighter O Gas Log
❑ Healing Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing O 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 # 5I407-UA:- Date
For office use only
Sob Site Addr (mqu/red)
,L Value of Construction (labor, materials, pit)
-1y
Ag .
C !i
PcaDertV Owner Na a Address
city/State ZIP
s
Phone
a� r 6?40
plimnt Nam'eA Address
/State Zip
Phone
A! i . L1 ti
90511
174• /
ntrador Address
e i to i
City/State Zip
. PL U 90a4 Y
Phone
yoey 8
Contractor City of Ft. Collins Sales Tax #
sales taanumberdradayaueonaaeom
Are you paying taxes here or by reports
Are
Here }s�.,��,,�port
OA
you paying with your trust aeoount?
Yes ❑ No
Is this a residential or commercial project? Rest ential ❑ Commerdal
If residential, is It: ❑ Single Family Deta ed Condo/townhome (single family attached) 0 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? o Yes 13 No Ffyes, you May neeato contact HlstoriCPreservabW
If this Is for a demolition permit, what year was the building constructed?
lfpdor to 1975, you W11 need an asbestos assessment to submit w9h thls applicabbn.
Description of work
*If lawn sprinkler/beekflow preventer, must Ilst Ilcansed plumber. If first-time A(C, must list licensed electrician.
subcontractorsr List the company name orOly of Ft Collins lfeerrse #
Electrician Plumber Mechanical Roofer Other
I hereby acknowledge that I have read this application and state that the above Information Is complete and corned. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building conMcdon. Y know that a
permit is not valid until it has been paid and Issued:
Applicant:
Print Name: (�6-m n'
JDate `�/'