HomeMy WebLinkAbout328 N ROOSEVELT AVE - APPLICATIONS - 1/6/2016From:
01/06/2016 05:58 #992 P.001/001
l3k4g16
Fort 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).
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑❑'Gas Logoning
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 # C7 IoO p?j I
foro>iice use only Date
------------
Sob Site Address (required)
Value of construction (labor, materials, profit)
Property Owner Name rl 69
Address City/State
Zip Phone
Applicant Name Address S
City/State Zip Phone
Contractor Address
City/State Zip Phone
Ie
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here s
sales tax numbera required by al cono-a�yo/� *Report
Are you paying with your trust account? Ayes C1 No
Is this a residential or commercial project? ��� ,,,nnn
If residential, is it: Single Family Detach gResidentlal ❑ Commercial
❑ Condo/townhome (single family attached) ❑Duplex
If commercial, is it: ❑ Bank e p Bar p Church C3 Ho ertment) 13 l/❑ ical office Motel Med
O Restaurant ❑ Other (explain) / Office ❑Retail
Is this building 50 years of age or more? ❑ Yes ONO 1f yes, you may/reed to contact Historic Preservat/on
If this Is for a demolition permit, what year was the building constructed?
If prior to 1975, you wiiineed an asbestos assesment to submit with this appiicabon.
Description of
*If lawn sprinkler/baclQlow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the company name or City ofFt Co//ins /icensP
if
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: //11
Print Name: �� C.o�Q tom; ��
Signature
Date