HomeMy WebLinkAbout414 HAVEN DR - APPLICATIONS - 10/7/2014City of
Fort Cottins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort 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). 0 Air Conditioning
A Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler q Mobile Home replacement WRoofing ❑ Sewer Line ❑ Photo-voftaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Peflet Stove (must be EPA certified, provide make, model and
manufacturer). 46
Complete all applicable Information on the application. Incomplete applications will not be accepted.
Application #bm I I0 Date a r i-
For off/ce use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
�¢ I7
Property Owner Name Address
Clty/State Zip
PhoneAj' a)
Applicant_ Name Address
Phon`e^'�c
jcity/State /Zip
Contra r Address
City/State Zip
Phone
afi rr r-1% h
76'- 54, � a- . r'ac1cL
BaA4- 5v(-v
Contractor City of Ft. Colli Sales Tax ,#
Are you paying taxes here orb report?
MlHere ❑ Report
Sales tax number ifrequlmdbyall con&adm..
Are you paying with your trust account?
❑ Yes P,' NO
Is this a residential or commercial project? ✓ rResidential ❑ 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 40 years of age or more? ❑ Yes ) No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? —.-
If P*r to 1975, you coil/need an asbestos assessment to submit with this application.
of work
If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician,
Subcontractors: List the company name or C/fy of Ft Collins /kense at
ElftVclan, _ 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: ` /,'
Print Name: Signature "`fir <�1Z�C`.Date
l
0Td Wdos:ZT bTOZ ILO 1100 ZPTS17£S80£: 'ON. XUJ : W08d