HomeMy WebLinkAbout4132 SUMTER SQ - APPLICATIONS - 8/4/2014Of
-Fort Collins
Planning, Development 8r 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). El Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not se ce 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).
I�3, �5
complete all applicableinformationon the application. Incomplete applications ill not be accepted.
Application # Date f " ' � r'� 0 �
For office use only CX
Job Site Address (re4u6ed) Value of Construction (labor, materials, profit)
o�n ij yt �Z� li/ 3� S I.l01 i
Property Owner Name Address Gty/State Zip Phone
n ho !Hf I, ur2r 'My-a°Y�o �
Applicant Name
Address City/State Zip Phone
Contractor Address City/State Zip Phone
Contractor City of Ft. Collins Sales Tax # %' — it 4
&i/es mx number Ls raqutred by all mvrbaeiois
K'Tn,l � a�-0g7g�37
Are you paying taxes here or by report? AHere ❑ Report
Are you paying with your trust account? El Yes ❑ No
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: A 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 eb No If yes, you may need to contact H/storlc Pieservatlon
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you call/ need an asbesws assessment to submit with this applkation.
Description of work re & C G /0 ° � S
*If lawn sprinkler/badkfiow preventer, must list licensed plumber. If first-time A/C, must fist licensed electrician.
Subcontractors: List the company name or City of Ft Colliers license ,# EA," /
Bectrician 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: AKAV-I t14v� Signature
Print Name: !/
Date
*/((