HomeMy WebLinkAbout4261 KINGSBURY DR - APPLICATIONS - 7/18/2014From All Phase Restoration Fax. r9?01 622-2057 To: Fay: +1 t970) 224-6134 Page 2 of 2 07/182014 12:21
City Of Planning, Development & Transportation
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281 N. College Ave P.O. Box 580
/ F6r`} ColtinS 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). O 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 ❑ 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 # 'V) Iq--C -1 �,-J Date 7
For office use only
Job Site Address (rewired)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address City/State Zip Phone
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Applicant Name
Address City/State ZIP Phone
1 Contractor
All
Address City/State Zip Phone
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7355 Greenr/doC 51-e A✓i�Z,2, Cd ��'N"
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? WHere ❑ Report
saes tax number is wgwredbyall contractors.
Are you paying with your trust account? ❑ Yes )<No
Is this a residential or commercial project? JK Residential ❑ Commercial
If residential, is it 9Single Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
11 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 JB No Ifyes, 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 applicat/on.
Description of work lee - rtv" w �'h 4k v
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty of Ft Collins license ,Y`
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:
Signature
Print Name: �m 11��i�
Date
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