HomeMy WebLinkAbout932 E PITKIN ST - APPLICATIONS - 7/10/2012Ju1.10. 2012 3:42PM No.4427 P. 1
City of eA
\ Planning, Development & Transportation
;��tCollins 281 N. College Ave P.O. Box 580
CFort Collins, CO B0524
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
ta
manufacturer).
Complete all applic ble information on the application. Incomplete applicatlons will not be accepted.
Application # (� � IS Date OrI110110i♦��
For office use only
Job Site Address.(requlred�_,,
�n
Property Owner Name Address
City/State Zip
Phone
Ku 1-e h 13 �
r~ i ho -ter, & F'o�f2
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Applicant Name Address
City/State Zip
Phone
kin) r' [.
lqve ► C'mve-v 6 26a/(0
3/aGitp -49�37
Contractor Lic # Address
City/State ZIP
Phone
A VL I I . G I a`] U C 5
,e eigVe-r '�'
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? fi'Here ❑ Report
Sales tax number 4srequl1e by&//conrractors
Are you paying with your trust account? ❑ Yes VNo
Is this a residential or commercial project? P'�'PlZesldentlal ❑ Commercial f N P—U L> ✓S HOL 5C Sh-C-®
If residential, Is it: Single Family Detached ❑ Condo/townhome (single family attached) q Duplex y
❑ 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 morel ❑ Yes 00 Ifyes, you may need to contact HlstorlcPreservatlon
If this is for a demolition permit, what year was the building constructed?
If prfor to 1975, you will need an asbestos assessment to subm/t with this app/lcatlon.
Description of work _ r v . 3 S 1 e., ,' s=at
i S'
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
subcontractors: List the company name or City of Pt Collins license t I
Electrician Plumber. Mechanical Roofer i La 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:
Print Name: j�l Vh U� Gc Y Signature etw� s f ^ Date r7 (l3 / d_