HomeMy WebLinkAbout1320 NASSAU WAY - APPLICATIONS - 5/12/2016May 101612:00p Northern Lights
303-774-1206 p.1
City of Plann
281 N.
FQ!�I } i Colli r1 IS ° Fort G
Phone
OVER-THE-COUNTER PE
This application is to be used toapplyfor the following permits onl
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not serve
❑ Heating Unit El Lawn Sprinkler; El Mobile Wcc Mobile Home replace
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ WoodlPellet Stove (mi
manufacturer).
Complete all applicable information on the application. Incomplete
Application # 151 100�5 Date _
For oifrce use only
t, Development & Transportation
Aege Ave' P.O. Box 580
is, CO 80524
0-416-2740 Fax 224-6134
MITS ONLY
t
pheck allithat apply). ❑ Air Conditioning
Mange) O Gas Lighter ❑ Gas Log
ng ❑ Sewer Line ❑ Photo -voltaic
be EPA certified, provide make, model and
mlicatioris will not be accepted.
Job Site Address ( ulredJ Value f Construction (labor, materials, profit)
Property Owner Name Address City/Sta e ! Zip Phone
�� ��T-r5 1132D t4�35a G'� (pt��nS` L'G .?76r2(s -62S-
Applicant Name Address City/Sta a Zip Phone
Contractor // rr Address City/State Zip Phone
f �or i'l�rn a� 5 1ct icr5 J i37S C1 91 2.3 9062/ &3 -77 6 -S2Gt
Contractor City of Ft. Collins Sales Tax # Are you paying laxes here or by report? ❑ Here ❑ Report
Sales tax number& required by all contractors Are you paying ith your tryst account? ❑ Yes ❑ No
Is this a residential or 94rimercial project? 9Aesidential ❑ Commercia
le fami
If residential, is it: Single Family Detached ❑Cando/townhome (sin ly attached) ❑Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medi I office ❑: Office ❑ Retail
❑ Restaurant ❑ Other (explai
Is this building 50 years of age or more? ❑ Yes No If yes, you may need to contact Historic Preservation
I If this is for a demolition permit, what year was the building constructed?
j df prior to 1975, you will need an asbestos assessment to submit with this ao Xloatton.
Description of work
*If lawn sprinkler/baci flow preventer, must list licensed plumber. If first-time
Subcontractors: List the company name or Oly of Ft Collins license #
Electrician Plumber Mechanical
must list licensed electrician.
Roofer 7 Other
I hereby acknowledge that I have readthis application and state that the above i formation 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.
r
Applicant:
Print Name: T ��% t�,�% Signature ) ate