HomeMy WebLinkAbout428 W OAK ST - APPLICATIONS - 9/30/2016City of d Planning, Development & Transportation
r / 281 N. College Ave P.O. Box 580
F6rt Collins Fort Collins, CO 80524
Phone 970-416-2740 Fax 22+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 # ���dJS"11� Date 30-14P
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
za w . 0&k S+. $
Property Owner Name
L' is 3 r S. ; e A1cYee
Address
zoq S.
City/State
Sherwj 04. F.C.
Zip
$D521
Phone
082-39')?
Applicant Name
Address
City/State
Zip
Phone
Contractor . Lic # Address
City/State Zip
5j1 f l_ ctr%11 LJ✓ �F �11,-2 171 CU- eV55U
Contractor City of Ft. Collins Sales Tax #� 1�(
Sales tax number is required by all contractors
Phone
Are you paying taxes here or by report? mere ❑ Report
Are you paying with your trust account? Yes vEMo
Is this a residential or commercial project? 17"Residential ❑ Commercial
If residential,. is it: I�Single Family Detached ❑ Condo/townhome (single family attached) ❑.Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑, Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes ER No -If yes, you may need to contact Historic Preservation
If this is for a dernolition permit, what year was the building constructed?
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work 'F'�e$?ac-e_ Itis,,r heu4ce- u-> t{ 74nVEs
*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 w r leW t7toe , 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: r t q
Print Name: �,/ r _ l/ Signature .WSJ Date /