HomeMy WebLinkAbout4271 SOUTHSHORE CT - APPLICATIONS - 6/8/2016 (2)City of
Fort Collins
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 # Z0 ? ?J 1614KOD-Li (0 Date e�
For office use only
3eb eftee Addr+es-s (rlutred)
Value of Construc-Ation (labor, materials, profit)
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Property Owner-1
Address City/State Zip Phone
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Applicant Name
Address City/State Zip Phone
Contractor
Address City/State Zip Phone
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Contractor City of F . Collins Sales Tax # Are you paying taxes here or by report? At Here ❑ Report
Sales tax number isrequired byall mnbactors
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? Mesidential ❑ 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 ❑ No If yes, you may need to contact Historic Preservation
If this is for a demolition per -nit, what year was the building constructed?
Ifprfor to 1975, you wi// need an asbestos assessment to submit with this application.
Description of work
*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 0
Elechidar�Xh Z 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.
Applicant:
Print Name: 14 Signature - pate Z !