HomeMy WebLinkAbout4349 KINGSBURY DR - APPLICATIONS - 6/23/2016Fort 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 (WA@4 r 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 # b 11102A- I �T-- Date Win , 7_;77? . ?fi b
For ofce use only
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name Address
City/State Zip Phone
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Applicant Name Address
City/State Zip Phone
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Contractor Address
City/State Zip Phone
Contractor City of Ft. Collins Sales Tax #
Sales tax number is required by all contractors
Are you paying taxes here or by report? ❑ Here ❑ Report
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: Wingle 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 SO years of age or more? ❑ Yes PMo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? (VLA
if prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work f .,sKoy't N6 C—Kt !�zM NOA bi C , ant S US_ 92sj o L-0 RC—Q L A CZM EIJ
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*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 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: Ll�a� 01y %� I Signature rL Date Z3 ,J\)w i 1p