HomeMy WebLinkAbout424 PINE ST - APPLICATIONS - 7/10/2015City of Planning, Development &Transportation
281 N. College Ave P.O. Box 580
Fort Collins 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) ❑ 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 # �l Sb52t U . Date 7116 SO /.57"
For office use only
Job Site Address (required)
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2 /"/ilk S'T �"DY� GO/!/�li
Value
Value of Construction (labor, materials, profit)
�e,57 7 "$1 � � , 00
Property Owner Name Address
City/State Zip
Phone
97,0
Applicant Name Address
City/State Zip
Phone
�Soyl Tv-, 2137
5P70-2zj
Contractor Address
City/State Zip
Phone
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�AZA_ e
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
Here OR ort
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes C-Y 0
Is this a residential or commercial project? ❑ Residential ITCommercial
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 GKqo If yes, you mayneed to contact Historic Preservation
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 A le'- �"�j�%`G�''�^ %`
d 4 `:Vfpl 1?ce!>M
*If lawn sprinkler/backfiow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
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: -�
Print Name: ""`sue �" "lam Signature9__� Date
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