HomeMy WebLinkAbout919 QUEENS ST - APPLICATIONS - 9/26/201110/24/2011 13:59 9702329739
City of
Fort Collins
PAGE 03/03
(]O"X clI zo I I t
Planning, Development A TranspottstiOn
281 N. College Ave P.O. Box 580
Fort Collins, CO W524
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 applyl.OWAir Conditioning
O Demolition (interior non-structural) O Electrical Alteration (not service change) O Gas Lighter O Gas Log
Heating Unit O Lawn Sprinkler O Mobile Home replacement O Roofing O Sewer Line O Ptwto-voltaic
❑ ventilation ❑ Water Heater O Water Line O 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 # DateFor ofte use only
30bSRO Address (required)
value of Consbnutlon (labor, materials, profit)
�y - S� 411
/�
� l
/' S
w 5--
Property Owner Name Address
Gty/State Zip Phone
70. G-V 36 g
Applicant Name f/-8L4( Address
Gty/State Zip Phone
Ali6a.,ck+s ONr m- ` 1-1 bENVEx- Y444C Lo►at cla (o 1013-7 9'h1•6
4 3 `fo0Z
Contractor u_92&f Address
City/State Zip Phone
1 A�i�t,.�.+3 Our goj6- L bcwvc,�
c
A-,r Lo✓c(•-,.jo C•+ OSrl / 0
613 y021
Contractor City of Ft Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here
J Report
Srlesraunumderisrequheiaeyalrmnoactws
Are you paying with your trust account? *0 Yes
❑ No
Is this a residential or commercial project'.' .-Residential O Commercial
If residential, is it: X Single Family Detached O Condo/townhome (single family attached) C3 Duplex
O Multifamily (apartment) O Garage
If commercial, is it: O Bank ❑ Bar O Church O Hotel/Motel El Medical office ❑ ofnce C3 Retail
D Restaurant C3 Other (explain)
Is this building 50 ymirs of age or more? O Yes ❑ No If yes, you may need to contact Historic PneservaWn
If this is for a demolltton permit, what year was the building constructed?
If prior to 1975, you wi// nod an asdestos asA mwent to submit wth this appAL-a on.
Description of work
'If lawn sprinkler/baddlow preventer, must list licensed plumber. If first -brae A/C, must list licensed electrician.
SubcontraMrs: Lfst lire company name or City of Ft Collins license 0
EIcandan Plumber Mechanical koofer Other
I hereby aduowiedge that i have read this application and state that the above Information Is complete and correct. I agree to
compty with all requirements contained herein and city ordinances and state laws regulating building construction. I knew that a
permit is net valid until it has been paid and issued.
Applicant' m�Date
Print Nae f;t L I C _ .. __ Signature _