HomeMy WebLinkAbout410 WAYNE ST - APPLICATIONS - 2/4/2015r .
Cityof Planning, Development &Transportation
} 281 N. College Ave P.O. Box 580
CQr' 1, �Collins Fort Collins, CO 80524
r..� Phone 970-416-2740 Fax 274-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply forthe 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 Cl 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 # 'PI 502-0-'�(_0 . Date 01—h
for office use only
Sob Site Address (required)
AD W491.01 S1. 9C
Value of Construction (labor, materials, profit)
5;1 a 007400
Pr erty Owner Name Address
11 Alln
City/State Zip
Phone
Applicant Nam �( Address
Sherri i'r7t(1 /D) S. L11U
City/State Zip
/1 0 y05ay
Phone
4Y0_ggq_ygq/
Contractor Address
City/State Zip
Phone
i 01 $- 1-hVitr
1,lt%• o Yr�S�y
�Qy SIPS//
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here 19keport
Saks MYnumberlsrequhedbyallConhVd0is,
io2Q
Are you paying with your trust account? ' Yes ❑ No
Is this a residential or commercial project•? Residential ❑ Commercial
If residential, is it: 'Ingle Family Detac ed ❑ Condo/townhome (single family attached) ❑ Duplex
*❑ Multifamlly (apartment) ❑ Garage
If commercial, Is It: ❑ Bank ❑ Bar ❑ Church p Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building So years of age or more? ❑ Yes ❑ No Ifyes, you mayneed to contact HistoncPresematlon
If this is for a demolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description 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 CO of ft Colllns license #
Electridan Plumber Methanleal 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. 2,1" Ir i G Q i ffnJ Signature l,,l l_1L4 ato ` 1
E /E # 8ttt-t8b-Mf :NVN:W96-0£-£0