HomeMy WebLinkAbout323 N WHITCOMB ST - APPLICATIONS - 11/14/2016City of
F,6rt 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 eWater Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information
//ow�n the application. Incomplete applications will not be accepted.
Application # Q1 Date W 1 LA U �o
For office use only
JobSiteAddress
Value ofConstruction (labor, materials, profit)
t �(rre�q�uirreed) p� L
323 Iva wyli WY►`�l S]hzaT
S1,100
Property Owner Name Address
City/State Zip
Phone
Co tgl �
W1 21 - M
Applicant Name Address
City/State Zip
Phone
L, ,S 9101ydm smabn ,lob. ii►cl 9ves
Use D ..#6 FA. Co�1tnS,Co �G52�1
C���221_}�?
Contractor Address
City/State Zip
Phone
(SaVU D,5 WOOVZ
Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here Ef Report
❑ No
Sales tax number is required by all contractors.
Are you paying with your trust account?
S(Yes
1q3'l l
Is this a residential or commercial project? d Residential ❑ 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 it No If yes, you may need to contact Historic Preservation
If this is for a demolition 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
*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: p p 1 R �r�A� Signature- p(� ,� _ 1 l Print Name:__ Sy Off \i�l�'� Date