HomeMy WebLinkAbout4501 REGENCY DR - APPLICATIONS - 6/15/2012NCR
FAX NO. :9702299983 Sun. 16 2011 04:42PM. P7/7
City of
11., �r t 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 Cl Water Heater D Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model an
manufacturer).
Complete all applicable Infor/mattioonn on the application. Incomplete applications will not be accepted.
Application #_ �✓ I c;)1'yw /� Date
t For office use only
Sob Site Address (requlred)
Value of Construction (labor, materials, profit)
Property Owner Na
Address
City/State ZIP
Phone
n.
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Applicant Name
Address
Oty/State Zip
Phone
Contractor
Address
Clty/State Zip
Phone pl_�la
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here
XReport
SWestax number isrequlredbyall cwitraeNrs
Are you paying with your trust account? %,Yes
A No
keF'to2-
Is this a residential or �co merdal project? C?rResi ntlal ❑ Commercial
If residential, Is It: .(id'SI gle Family Detached Condo/townhome (single family attached) . ❑ Duplex
�j Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ ear ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explal )
IS this building 50 years of age or more? ❑ Yes ANo If yes, you may need to contact H/sforlCPresertat/on
If this is for a demolition permit, what year was the building constructed?
Ifpnor to 1975, you will need an asbestos assessment to submit with Hula application.
Description of work
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Ust the Company narhe or City of Ft Collins license 0
Electrician 1%lN�'� Plumber
Mechanical Roofer
pthcr
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 Nam
Date CIO-IS-1 Z`