HomeMy WebLinkAbout640 ENDICOTT ST - APPLICATIONS - 4/16/2012Cli
Fort Collins
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) ❑ 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 #
For office use only
Date
Job Site Address (required) , Value of Construction (labor, materials, profit)
640 alAtG6-tr $ mect. 11-415. °y 37 /-?
Property Owner Name
Address
City/State
Zip
Phone
6510 ►�
"' ,cclllA+t Cc,
�'or2y
214 -�i8s
Applica t Name
Address
City/State
Zip
Phone
rX "j' /MOYA'Aw
612 E 1AUK1 .3�f ull CO
Ifm Y
.2 Z32
Contractor ,
Lic # Address
City/State
Zip
Phone
o"AJ R. A
9-1222 ll
11
n
r ,
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
ere ❑ Report
sales tax number is required by all contractors
y1067
Are you paying with your trust account?
❑ Yes ❑ No
Is this a residential or c9mmercial project? A Residential ❑ Commercial
If residential, is it: Single Family Detached ❑ Condo/townhome (single family attached) ❑ 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? ❑ Yes �dNo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If pnor to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
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 Name0?qbJ t L A10f,094)1J Signature Date / �/ A/ -
201Z
City off Planning, Development & Transportation
FOr t Collins Fort Co I ns, CO 80524 A. Box 580
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) 0 Electrical Alteration (not service change) ❑ Gas Lighter 0 Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
* Ventilation ❑ Water Heater ❑ Water Line D 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 #,
For orrice use only
Date
Job Site Address (required) , Value of Construction (tar, materials, profit).
6140 gNd.ieor r $ Myt '3?J 2, Z/3
Property Owner Name
Address
City/State
Zip
Phone
f kabliSLI TLAlki OV
1`NdI G6tt
COI
OR 9
2- /5 - Mr
Applica Name
Address
City/State
Zip
Phone
61 z
F ZAUrcl
V
Z32
j Contractor , Lic #
Address
City/State
Zip
Phone
D�
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
ere ❑ Report
sans tax number is requited by all conbactars.
Are you paying with your trust
account?
❑ Yes ❑ No
i -- '!106y
is this a residential or commercial project? Akesidenttal ❑ Commercial
If residential, Is It: 17 Single Family Detached ❑ Condo/t wPh (single family attached) ❑ Duplex
17 Multlfamiiy (apartment) >kGara Y� e
If commercial, is it: ❑ Bank O Bar ❑ Church 0 Hotel otel ❑ Medical office 0 Office ❑ Retail
O Restaurant Gi Other (explain)
Is this building SO years of age or more? ❑ Yes A No If yes, you may need to contact H/stOM 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 subailt with this appl/cation.
Description of work X f ft oyC !- ZAye"- -to /,ie .. 4.4 1. rtdy aid ilk
*If lawn sprinkler/backflow preventer, must list licensed plumber. if first-time A/C, must list licensed electrician.
Subcontractors: list the cvmpany name or Oty of R Collins license #
IElectrician __ Piumber__ Mechanlcal 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.
arrt: Print j) k ----!% �—
Print Name:(�/G L %1�SIt'krV 5lgnature_Date -