HomeMy WebLinkAbout619 MANSFIELD DR - APPLICATIONS - 8/24/2016City of
Flirt 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 #y?1(D049oZC1
For off1ce use only
Date S/a-4 A uv
lob Site Address (required)
Value of Construction (labor, materials, profit) .1W_i V V
14 Alt s-Fie (J
f9f-14-Co 143 60 g os Zs— 900 8Zz s226
Property Owner Name Address
City/State Zip Phone
40 qorz 26 g- 1 ;;tt
Applicant Name Address
City/State Zip Phone
Contra or Address
City/State Zip Phone
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here ❑ Report
swestax number isrequired byall contractors.
Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? ,Residential ❑ Commercial
If residential, is it: 13 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 SO years of age or more? ❑ Yes 0'No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? /V%
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work r' M.r_l Gt, *. C Lem, li 4- /`�\ dp c vnn.e c-t 4-
/�J sprw � cz 2n�-� cz �_ch, le S-eryiC4gr'o�, i'a t S Oa. �,� -arn. 16De+.
*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: I
Print Name: w Signature Date l 2%