HomeMy WebLinkAbout410 WAYNE ST - APPLICATIONS - 3/14/2016Fo`�rt Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134
1
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
manufactu,rer).
Complete; all applicable information on the application. Incomplete applications will not be accepted.
Application # Date
For office use only
Job Site Address (required) L11 o
Wd�y� S� Value of Construction (labor, materials, profit)
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Property Own r Name
Address
City/State Zip Phone
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Applicant Name
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Address
City/State Zip Phone
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Contractor
Address
City/State Zip Phone
0.51
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Contractor City of Ft. Collins Tax #
Are you paying taxes here or by report? e . ❑ lz eport
sales tax nuinberisrequiredbyall conlraclors
Are you paying with your trust account? ❑ Yes No
Is this a residential or commercial project? residential ❑ Commercial
If residential, is it: 0 Single Family Detached ❑ Condo/townhome (single family attached) ' ❑ Duplex
Ep Multifamily (apartment) arage
If commercial, is it: 0 Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
El Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you mayneed to contact Historic Preservation
If this is fora demolition permit, what year was the building constructed?
Ifprior to 1975, you W111 need an asbestos assessment to submit wdh this application.
Description of work
*If lawn sprinkler/baddlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
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.
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Applicant: 1(t�
Print Nam : � Signature — \ paw