HomeMy WebLinkAbout654 MANSFIELD DR - APPLICATIONS - 9/22/2015City/ of Planning, Development & Transportation
} 281 N. College Ave P.O. Box 580
�.
�i ` CoLLI I.n 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 ❑ 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 Date _�I�`Z
For office use only
lob Site Address (required)
Value of Construction (labor, materials, profit)
6569 Mav- e LC( /` f
Co I I t eq O S'
Property Owner Name Address
City/State Zip Phone
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[Applica?4Name
C �f7L l� l �S — L`
Address
City/State Zip Phone
Contractor Address
City/State Zip Phone
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Contractor City of Ft. Collins S4 Tax #
Are you paying taxes here or by report? Mere ❑ ort
Salostax number isrequired byall contactors
Are you paying with your trust account? ❑ Yes o
Is this a residential or commercial project?
If residential, is it: ❑ Single Family Detac
❑ Multifamily (apartment)
If commercial, is it: ❑ Bank ❑ Bar ❑ Church
sidential ` ❑ Commercial
❑ Condo/townhome (single family attached) ❑ Duplex
❑ Garage
❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
If pr1or to 1975, you will need an asbestos assessment to submit with th/s application.
Description of work
*If lawn sprinkler/baddlow preventer, must list licensed plumber. If first-time A/C, must
Subcontractors: List /fie company name or City of Ft Collins license #
Electrician Plumber
licensed electrician.
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 (dame: Signature
Date