HomeMy WebLinkAbout4700 REGENCY DR - APPLICATIONS - 4/25/20177-7
of
Collitl5
Planning, Development a Transportation
281 N. College Ave P.O. Box 580
Fort Collins, OD 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). O Air Conditioning
O Demolition (interior non-structural) O Electrical Alteration (not service change) O Gas Lighter O Gas Log
O Heating Unit O Lawn Sprinkler O Mobile Home replacement O Roofing O Sewer Lme O Ptoto-voltaic
O Ventilation O Water Heater O Water Line O Wood/ftlet Stove (must be EPA certified. provide make, model and
manufacturer).
Complete all applicable Information on the application.
Applicatim #_ 1)11() al -4-4
For dit a im ono,
Incomplete applications will not be accepted.
Date 4/2-5-1/7
gob SRO Address (regulmd) -
!fairs of Construction (labor, materials, profit)
a0
Property OwneVName / Address
Clty/State Zip Phone
N 700
�L EGG
-4e413
Applicant P6me Address
City/Statie Zip Phone
Contractor Address
City/State Zip Phone
Contras" City of Collins Sales Tax 9
Are you paying axes here or by report? )Of Here
O Report
Saves��rrnrenbertsre dbyair cxftavm
Are you paying with your trust account? O Yes
❑ No
Is this a residential or
project? [Residential O Corronercial
If residential, is it: Single Family Detached O Condo/townhome (single family attached) O Duplex
Muttifang* (apartment) O Garage
If commercial, Is It: O Bank O Bar O Church ❑ Hotel/Motel O Medical office O Office O Retail
❑ Restaurant 13 Other (explain)
Is this building 50 yam of ape or more? O Yes O No If yes; you may need to contact HLswt pAw&vah+on
If this Is for a demoNtkm wit, what year was the building corhstructed?
Ifpr& to 1975, you wit/ need an asbbesios asoessrme to w&7rit *0 this alibi ifon.
Description of work
*If lawn spxinlder/baddlow preventer, must DA tfoensed plumber. If first-time A/C, must list licensed electrician.
Subcontrscbors: List the company name or Oty of R Co//!ns fica Ae 0
Plumber Roofer 06W
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 n Signature Dale
029JO �J /9 r /fi /33 9d