HomeMy WebLinkAbout925 COLUMBIA RD - APPLICATIONS - 6/20/2015City of Planning, Development & Transportation
p� 0 281 N. College Ave P.O. Box 580
F6III���{� F1 C�9W s 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 K 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 # k5 (`PDf5`f `'5 � Date �o
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
Qv5 6:.. W5'3_�
f l 2l-w-
roperty Owner Name Address
City/State Zip 61)5a 5 Phone 1 0
� .&01 Cvt-10 15 aL t_ PkU i .,- ' CJ a) IAQ.G MS 213 - 44 G )
Applicant Name Address
a' F __b,2,1 w
City/State Zip Phone Q 10 -
LOve(a�-i:( Co 3u'1 I
/-t���.,
Contractor Address
Zip Phone 6��'`tG
�7C'_i"1 \0.i^r1 �;1 E'4 07�1(..�.�in_ �� �t ivttj � ;i:%I .
\City/State
�•'� `� Uii.Yl�-e;✓ t'_1�•'� , L�Civ-£�lA,,-,;� �:l) 411151J�
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? WHere nReport
Sales tax number is required by all contractors.
Are you paying with your trust account? R Yes ❑ No
Is this a residential or commercial project? 1)13Residential ❑ Commercial
If residential, is it: ❑ Single Family Detached `6/7 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 ❑ No Ifyes, 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
*If lawn sprinkler/backflow 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 Name8a r t" 19Ck ld'YLZr Signature
Date U I !dO 115
iI