HomeMy WebLinkAbout4702 DUSTY SAGE DR - APPLICATIONS - 10/21/2014Fort CoWns
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
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 XRoofing ❑ 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 # l?:;, 14-11�r�, Date
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Property Owner Name Address
City/State Zip
Phone
-Hahong RRoA 8G Y�ait•t Co1,-^s CO SOS S
222 -9393
Applicant Name Address
City/State Zip
Phone
aw 194— PAS `s 1800 F, rVILierrX
Fkelb
6-;03-71
Contractor Address
City/State Zip
Phone
MvSk�j
;6L(AIA5 80sa
`97D—Al 719
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ jiere ❑ Report
sales tax number is required by all conbwctors.
Are you paying with your trust account?
es ❑ 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 XNo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? NA
If pricr to 1975, you will need an asbestos assessment to submit with this application.
Description of work
*If lawn sprinkler/bacidlow preventer, must list Iicen'sedplumber.
A/c, must list licensed electrician.
Subcontractors: List the company name or City ofR colllns license # 1
Electrician Plumber_ Mechanical__ Roofer , 1'1buS` 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: /� I 1 , p �.�
Print Name: t—K 6ppe— Signature, �— Date