HomeMy WebLinkAbout4501 CLIFFSIDE CT - APPLICATIONS - 1/12/2015City O'f ,, Planning, Development & Transportation
��� fir+} I • n 281 N. College Ave P.O. Box 580
of ` CottiI IS Fort Collins, CO 80524 _
�— 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) El Electrical Alteration (not service change) El Gas Lighter ❑ Gas Log
❑Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement Aloofing ❑ 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 #.
For office use only
Date /-/t),--/S-
Job Site Address (required) Value of Construction (labor, materials, profit
Pty Owner Name Address
City/State Zip
Phone TV
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Applicant Name Address
City/State Zip
Phone
Contractor Lic # )—I�'J Address
o re 11 y+
City/State Zip
Phone q—lU
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Contractor City of Ft. Collins Sales Tax # y \ �(✓p
Are you paying taxes here or by report? ❑ Here
X Report
Sales tax number is required by all contractors
Are you paying with your trust account? X Yes
❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: CIA 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 i�_'No If yes, you mayneed to conlactHistoric 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 application.
Description of work 7tf 2 (Zed )c B x'yC O a vA,' ro .02 cAt /{Q,a Lx'rne w y
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*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed el ctrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician 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: c; v �j
Print Name: - E' ` Signature
Date
/- / X -/Z-
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