HomeMy WebLinkAbout4501 REGENCY DR - APPLICATIONS - 10/7/201511-02-15;09;01AM; ;970-484-4448 # 2/ 7
City of
:.,-,o 'i Colt -ins
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Planning, Development Fc Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
OVER-THE-00UNTER 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 C3 Gas Log
H.�ating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line 0 Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, modal and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # 1,1 Jo 7 r `5
Poi- offleo use only
Date I d -0-l60
Job Site Addy (requlred)
Value of Construction (labor, materials, proFlt)
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Prop °rty Owner Nam
Address
city/state Phone
Applicant Nam
a
Address
City/state Zip
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Phone
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Contractor
Address
City/state Zip
Phone
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Contractor City of Ft. Collins Sales
Tax #
Are you paying taxes here or by report?
❑ Here 10eport
s,7/u ea% numbarisrwuGed byall ronn-act=.
_ ionl6
Are you paying with your trust account?
' Yes ❑ No
Is this a residential or commercial project? )SResddendal ❑ Commercial
if residential, is it: GI Single Family Detached �gCondo/townhome (single family attached) El Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, Is it: i7 Bank ❑ Bar El Church ❑ Flotel/Motel ❑ Medical office 0 Office ❑ Retail
❑ Restaurant ❑ other (explain)
Is this building 50 years of age or more? 17 Yes t7 No Dyes, youmayneed to contact Hlstor/cPreservatlon
If this is for a demolition permit, what year was the building constructed?
Ifpiyvr to 1975, you avlll need an asbestos assessment to subrrAwlth this applleadon.
Description of
":If lawn sprinkler/backilow preventer, must Ilst licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: Llstthecompanyname orGtyofAeColllnellcense#
tlacirician Plumber Mechanical Roofer Other
f horeby 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 N.0" t l� RI FfAJ Signature