HomeMy WebLinkAbout612 PROUTY CT - APPLICATIONS - 11/2/201111/02/2011 09:20 9704844373 BALANCE POINT PAGE 02
City, of f/''"''��� (Planning, Development & Transportation
281 N. �rl �..�.JltII1S Fort ColUhsCO 80524 ollege Ave O. Box SBO
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
0 emolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gaa Log
Z2
eating Unit 0 Lawn Sprinkler ❑ Mobile Home replacement 0 Roofing ❑ Sewer Line ❑ Photo -voltaic
Ventilation El Water Heater ❑ Water Line Q Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer)_
Complete all applicable Informatlon on the application. Incomplete applications will not be accepted.
Application # Date
For ofte use only —
Job Site Address (reV#red)
/c2
C ,Y e5
Value of Construuon (labor, materials, profit)
yyoo, a a
Property Owner Name
Address a
City/State
Zip Phone
rcieo� X'el
e-e. �T S
Applicant Name
Address
City/State
Zip. Phone
QC& Me �rblcY4 &-t `,A
dr 41
&Jo
rr zw-jra
Lonlnaww
Dr vSS�o y 490
Contractor
Address
City/State
Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? 0 Here 00 Report
Was, &WmniberisnWuneabya#conftewls Are you paying with your trust account? J13 Yes 0 No
MU
Is this a residential or commercial project? JResidentlal ❑ Commercial
If residential, Is It: ❑ Single Family Detached )R25ndo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, Is it: O Bank ❑ Bar C] Church 0 Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other(ex lain
Is this building SO years of age or more? Cl Yes No If yes, you may need to contact Historic preservabbn
If this is for a demolition permit, what year was t e building constructed?
If prior to 1975, you will need an asbestos assessment to submit w#th this applKafton..
Description of work
*If lawn sprinkler/backilow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the company name or pry of R Collins Ikleno #
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 but Ing construction. I know that a
permit is not valid until It has been paid and Issued.
Applicant: L
Print Name: 'n vS Signature Date �7