HomeMy WebLinkAbout630 W OAK ST - APPLICATIONS - 5/23/2016W, City of
Fort C�� dins
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.
Application # ` J f0- —1 iq . Date
For office use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
f6'131 GJ . �a�i�
f o ob,,
Property Owwner Name ` Address
Jc.o` ��'{f Ir�tl� 32�Z
City/State Cp Zip e cy2_� Phone
c;6t1�-J Pue: r q�'=' i(7- )(..Z.
Applicant Name Address
City/State Zip Phone
Contractor Address
or► �C ,,� �► vvl
City/State L_"z' Zip ec,3a ro Phone
> c�C it 71 15c, t l (GL-
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by all contractors.
Are you paying taxes here or by report? ❑ Here El Report
Are you paying with your trust account? ❑ Yes No
L.Qn Ala is
Is this a residential or commercial project? �1 Residential ❑ Commercial ON,,, �.c�
If residential, is it: Single Family Detached ElCondo/townhome (single family a-- : ed) ❑ 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 If yes, you may need to 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.
of work
2.
*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 Mechanical 'ZZ- 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:
Print Name .�,JUC, Signature
c.J
Date J5_"�346_