HomeMy WebLinkAbout612 BALSAM LN - APPLICATIONS - 4/20/201204/20/2012 13:37 9708973151
of
F City Collins
ROBERTS HEATING& AIR
PAGE 01/01
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) ❑ Cleetrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ ventilation 0 water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be CPA certified, provide make, model and
manufacturer).
Complete all applicable Information on the application. Incomplete applications will not be accepted,
Application # a� a Date i d ZQ 1 2
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
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Contractor City of R. Collins Sales Tax ffi
Are you paying taxes here or by report? 4 Here
❑ Report
Sales tax number I% required by all contractors.
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Are you paying with your trust account? ❑ Yes
W No
Is this a residential or commercial project? ® Residential ❑ Commercial
If residential, is it: 0 Single Family Detached 0 Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) 0 Garage
If commercial, is it: ❑ Bank ❑ gar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? 0 Yes III 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
*If lawn sprinkler/backtlow preventer, must: list licensed plumber, If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or city of Ft coins license #
Electrician Plumber Mechanleal 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: t I�� + ", t`" ^ Signature