HomeMy WebLinkAbout947 WORTHINGTON CIR - APPLICATIONS - 1/30/2015Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-274d 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 ( al) ❑ 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 # Date
For office use only
Job Site Address (required)
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Value of Construction (labor, materials, profit)
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- 80526 V0 000
Property Owner Name Address
City/State Zip
Phone
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Applicant Name Address
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Q City/State Zip
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Phone
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Contractor /� Address
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City/State Zip
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Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here KReport
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes KNo
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
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes X No If yes, you may need to contact Historic Preservation
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 this applicadon.
Description of work
Ova
Office ❑ Retail
1'D ✓L-
*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 Col/ins license #
Electrician_____— Plumber v 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.
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Applicant: 1 J / Z7Z U-1-E
Print Name:16 "40'2 Signature Date