HomeMy WebLinkAbout1418 SALEM ST - APPLICATIONS - 11/30/2015Fort Collins
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). ❑ Air Conditioning
EI 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
7 Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application.
Application
For office use only
Incomplete applications will not be accepted.
Date
lob Site Address (required) I !Value of Construction (labor, materials, proft)
/�1/0Y.SAZ&1 S7; $ /2SZ7`
Property Owner Name
l V/8
Address
City/State Zip Phone
bo525 970
Applicant Name Address City/State Zip Phone
Contractor uc # Address City/State Zip Phone
910S-2-G 4170-2Z.5--Z7_92_
:ontractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? XHere ❑ Report
Sake✓ tax number Is required by all conbacmns Are you paying with your trust account? ❑ Yes ❑ No
is this a residential or commercial project? 15Y Residential ❑ Commercial
IF residential, is it: O'Singie Family Detached ❑ Cohdo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
a commercial, is it: ❑ Bank . ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office I] Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes jrS No If yas, you may need to contact Historic preservatlon
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.
5a 19
Descriptioni of work C+iiLyn & QVr Sa G.rc(_o t"� rjL
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors, Lk t the company name or City of Ft Collins license #
,lectrician Plumber %i f� 25y Mechanical Roofer Other o
hereby acknowiedge 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 Flame: die AA&t- P-T-Pt I Signature /l ei Date r I ✓7d�/ s