HomeMy WebLinkAbout4240 BREAKWATER CT - APPLICATIONS - 11/21/2016From
11/21/2016 11:08 #400 P.001/001
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FCity of -
®r-t Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 470-416-2740 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
VHeating 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 # � � Date _ _ %k\_z_% la
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
l
Property Owner Name Address City/State Zip Phone
Applicant Name Address City/State Zip Phone
Contractor Address City/State Zip Phone
Contractor City of R. Collins Sales Tax # Are you paying taxes here or by report? ®(Here *Report
Sales tax number rs required by all contractors Are you paying with your trust account? )K Yes CI No
Is this a residential or commercial project? WResidential ❑ Commercial
If residential, is it: mangle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
0 Multifamily (apartment) 0 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 ONO If yes, you may need to contact Histodc.Preservahon
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 wa
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time NC, must list licens�IectritQ.,
>�� Subcontractors: List the company name or City of Ft Collins license � ���
Electrician Plumber Mechanical Roofer j+" . Ver
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:NIL &,L L)!�M Signature,, t - ��— Date