HomeMy WebLinkAbout4809 BRUMBY LN - APPLICATIONS - 10/13/201510-13-15;12;46PN;
of
Flirt CoRinS
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
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). 0 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 # Rl sb - ,A-1 i Date
For office use only
Job Site Address (required)
Value of Construction (labor, materials, pmflt)
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Property Owner Name
Address
Ci `ty/state 7Jp
Phone
kt Ut H209
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Applicant Name
Address
City/state Zip
Phone
Contractor
Address
City/State Zip
Phone
k�kd-s'p\mhn CA A keo'4A333
"`5} SE lOu land 005 7
U(6 -6
Contractor City of R. olllns Sales Tax #
Are you paying taxes here or by report?
Here ❑ Report
Sales mxnumverlsmyrifudbyallconftcmrs.
Are you paying with your trust account?
Yes ❑ No
N/OIeS
Is this a residential or c9inmercial 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? ClYes XNo 1f yes, you may need to comwtHlslnrIc Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprlor to 1975, you will need an asbestos assessment to submit with this appllcatlon.
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: Ustthe company name orCItyofFtColllnslicense #
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.--T) 3 P(.VM6 In
Print Name:-R-k n u r n f� Signature V Date