HomeMy WebLinkAbout619 MANSFIELD DR - APPLICATIONS - 4/12/2016City of Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins Fort Collins, CO 80524
Phone 970-416-2740 Fax 224-6134 S
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 servic ange) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement ErRoofing ❑ 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
n on the application. Incomplete applications will not be accepted.
Application #_ � 0103 D � 3 Date
For o ice. use only �5
lob Site Address (required)
t, ,� 1 P
Value of Construction (labor, materials, profit)
�,� i� 7o-y.0-77e
Property Owner Name Address
City/State Zip
Phone
Applicant Name Address
City/State Zip
Phone
Contractor C'o'ze- Address
City/State Zip
d ► ue- f L o
Phone
( o3 -957-63
Contractor City of Ft. Collins Sales Tax #
sales tax number isrequired byall contractors
Are you paying taxes here or by report?
Are you paying with your trust account?
❑ Here ❑ Report
❑ Yes ❑ No
Is this a residential or commercial project? E�-Kesidential ❑ Commercial
If residential, is it: 9/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 ❑ No Ifyes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was theibuilding constructed?
If prior to 1975, you will need. an asbestos assessment to submit with this application.
*If lawn sprinkler/backflow 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 #
Electrician Plumber iiMechanical Roofer rt��� 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: `
Print Name:&&�W�� �CrZ1'l� Signature240�01/ Date