HomeMy WebLinkAbout412 SMITH ST - AFFIDAVITS - 8/30/2016City/Of Building Services
PO Box 580
Fort Collins 281 N College Ave
Fort Collins, CO 80524
970-416-2740 phone 970-224-6134 fax
HOMEOWNER AFFIDAVIT
I/we, as owner(s) of record of the property located
At: LA Z 1-� \ �W\ Fort Collins, Colorado, hereby declare and attest
to the following: (please check only the one that applies):
OPTION 1:
❑ I am/ we are acting on my/ our behalf for the purpose of obtaining a building permit and
personally constructing my/our home. The home to be constructed is on the above property and
will be my/our Primary residence. I/we have not personally constructed any other new homes
in the Fort Collins city limits within the past 24-month period..
OPTION 2: /
�I I am/we. are acting on my/our behalf for the purpose of obtaining a building permit and
personally constructing an alteration or addition to my/our house, acting as our own general
contractor. The house to be altered is on the above property and is my/our personal prima
residence.
OPTION 3:
❑ 1 am/we are acting on my/our behalf for the purpose of obtaining a building permit and
personally constructing a non-structural alteration to my/our attached single family dwelling
unit. The house to be altered is my/our personal Primary residence. I am aware that I/we
cannot do any structural, electrical, plumbing or mechanical work and must hire
contractors/subcontractors who are currently licensed and insured with the City of Fort Collins.
I am/we are personally performing all of the work or hiring City of Fort Collins licensed trades people, or will be
continuously supervising unpaid volunteers (see Option 3 for attached dwellings). The work is directly related
4� a-,-�the,constructi o ,f.,,the,abovezfeferenced home, which is described more fully on Permit Application #
IJ -_ I;� , :(obta Weds#rom the Building Services office).
I/we uriderstan That any person(s) or agent(s) contracted to perform structural wood -framing, plumbing,
HVAC, electrical or roofing work, MUST BE licensed contractors in accordance with the regulation of the City
of Fort Collins. :
I/we understand that failure to comply with any of the above conditions may result in revocation of any permits
associated with the above Permit Application number, forfeiture of any fees that have been collected; a Stop
Work Order and potentially a court summons.
Sign in the presence of Notary Public
Own Co-owner
The foregoing Affidavit was acknowledged before me on this 2 o v day of
14t�1 C� li15 , ? 0Ito (month, year) by�r�l�d b �
Witness my hand and official seal
My commission expires:
MELISSA NELSON
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID ## 20164010301
MY COMMISSION EXPIRES 03-14-2020
Notary Public
Revised 611012014