HomeMy WebLinkAbout645 STONEHAM CT - APPLICATIONS - 3/2/2012._03/02/2012 16:36 9702329739
of
Fotrt Collins
planning, Development Ilk Tlansportstion
281 •N, College Ave P,O. 8011 S80
Fort Collins, Co BOS24
Phone 970-416-2740 Fax 224-6134
PAGE 04/04
OVEWTHE-COUNTER PERMITS ONLY
This appllwtion is to be used to apply for the following permits only (check all that apply). Conditioning
O Demolition (interior non-structural) ❑ Electrical Alteration (not service Change) O Gas Lighter ❑ Gas Log
)Qlieating Unit O Lawn Sprinkler ❑ Mobile Home replacement O Roofing ❑ Sewer Line O Photo-vORWC
O Ventilation O Water Heater O Water Line O 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 I a_0 ).D
For office use only
yob Site Address (required)
property Owner Name
Applicant Name N-8LY
A\ba"4S C)NC 40-kd—
Contractor 0 -1'2r(
Address
Address
42-1 bcfJvfx
_A Owe rt 6
Contractor City of Ft. Collins Sales Tax #
resales lax numbers required by all conrr Mis.
Address
Date 3' 2_' / c�0.00
value of construction (labor, materials, profit)
city/state
City/State
Gty/State
v[ti A✓� LoyE (f+..ro C.
C J
Phone
Phone
970.4C: y0u2
Phone
di n 913 V00 7-
Are you paying taxes here or by report? ❑ Here ArRepOrt
Are you paying with your trust account? )? Yes • O No
Is this a residential or commercial project? Residential O Commercial O Duplex
If residential, is it: `>�ing1e Family Detached O Condo/townhome (single family attached)
ff Multifamily (apartment) O Garage
If commercial, is it: O Bank ❑ Bar ❑ Church ❑ Hotel/Motel O Medical office C] Office ❑ Retail
O Restaurant O other (explain)
Is this building 50 year's of age or more? ❑ Yes CI No !f yes, you may need to contact Historic prpservagon
If this Is fora itioneed
permit, �� ei
!/pror to 1975, you edas asent to submt with this appliapon.
Description of work
'If lawn sprinkler/backflow preventer, must list licensed plumber. if first-time A/C, must list licensed electrician.
Subaomtractors: List the Company name or City of Ft Collins license e
Plumber Mecnanicai Roofer �� Otfler
Electr>aan._---l-- _-
t hereby ackrawkxlge that I have read this application and state that the above information is complete and correct. I agree to
comply with all requirements 0ontained herein and city ordinances and state laws regulating building construction• I bow that a
permit Is not valid until it has been paid and Issued.
Applicant: Date
Print Name: C t __..—.__ — �S' ignature