HomeMy WebLinkAbout600 BREAKWATER DR - APPLICATIONS - 9/5/2014Planning, Development & Transportation
City/ of 281 N. College Ave P.O. Box 580
F6r't Collins is 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 # 115WIOS S Date
For office use only
Job Site Address (required)
a
Value of Construction (labor, materials, profit)
Value
� C—
// .
l'00 �r�
_ -
Property Owner Name Address.
City/State
Zip Phone
lI --
�J L.L�(y.A - ✓C- 4e-1
Applicant Name q�� , o Address
�a� `� GL✓la„`2J� o�lla
City/State n
�G��rv�n�JF-L�- !K _
Zip Phone
1-. �_ �OSacJ act 513
Contractor
City/State
Zip Phone
I (( _�A��ddress
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by all contractors
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? ❑ 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 ❑ No If yes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you will need an asbestos assessment to submit with this application.
Description of work t`-4—
*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: L
Print Name: ° Signature Date