HomeMy WebLinkAbout4501 REGENCY DR - APPLICATIONS - 10/7/2015 (2)11-02-15;09;01AM; ;970-484-4448 # V 7
City G'r
:� -CoW s
Planning,. Development u Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224.6134
OVER-THLE-00UNTER PERMITS ONIN
This application is to be used to apply for the following permits only (check all that apply). Air Conditioning
0 Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Light ❑ Gas Log
❑ Ideating Unit 0 Lawn Sprinkler ❑ Mobile Home replacement ❑ Roofing ❑ Sewer Line ❑ Photo -voltaic
0 Ventilation ❑ Water Heater 0 Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, modal anti
marndacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application #.,_ 1� IS0 77 Date Ab- %7—
For office use only
I b Site . ss (required)
Value of Construction (labor, materials, proflt)
Prop rty Owner N me
Address
City/State Zip Phone
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�Applicant Nan;
Address
City/State ZIP
Phone
�70-i13q,$L!J
Address
City/State Zip
Phone
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I e I S. thM 41- El r? 0 FI)6aV
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Contractor Clty of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Report
:,ails MIN nUmber Isrequired by0cora6acturs
loaln
Are you paying with your trust BCcount?
Y-Yes ❑ No
Is tills a residential or commercial project? ' lResidential ❑ Commercial
If residontal, Is It: [I Single Family Deta ed ondo/townhome (single family attached) ❑ Duplex
El Multifamily (apartment) ❑ Garage
If Commercial, Is It: ❑ Bank 0 Bar ❑ Church 0 Hotel/Motel ❑ Medical office ❑ Office ❑ Retc-iil
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes a No Ifyes, you mayneed to cont3ctH1stor/cPreservat1on
If tills Is for a demolition permit, what year was the building constructed?
If prior to 3975, you rvlllAed an 'asbestos assessment to subm/t w/bh this application.
Description of work
*IF IaWn sprinklerJbaCkflow prevenler, must list licenses plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or 0ty of Ft colllns //tense #
Mcdrician Plumber Mechanical Roofer Other
I 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 bbeen paid and issued.
Applicant: I ' —Ld
Print Name. J�19X-CI �%I�iPla Signature