HomeMy WebLinkAbout604 CORNELL AVE - APPLICATIONS - 2/18/2016Cityof
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). ❑ 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.
f31 00 a4vqj_
Application # Date -'r �� , 201 lP
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
te ' oA CIO -VAe& t �v
Z a0
Property Owner Name Address
City/State Zip Phone
Applicant Name Address
City/State Zip Phone
-c>rta fly- as 15
M, v' 6r-e-ea.-mo
Contractor9"/lip Address
City/State Zip / Pho7n�e'1
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? �0 Here ❑ Report
5alestax numbcrisrequired byall contractors.
Are you paying with your trust account? �A Yes ❑ No
Is this a residential or commercial project? 19 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? ❑ Yes V No Ifyes, you mayneedto contact Historic Preservation
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.
Description of work
*If lawn sprinkler/backFlow Veventer, must list licensed plu4er. If first-time A/C, must list licensed
Subcontractors: List the company name or City of Ft Collins license #
Electrician Plumber
Mecha
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: �1 '
Print Names.•/. ' ( - ' Signatur 0 Pit 1-o-z-QJdI � Date
9�"&k