HomeMy WebLinkAbout114 BRISTLECONE DR - CORRESPONDENCE - 8/24/20177 (COLORADO
Office of Behavioral Health ' o h
Department of Human Services
SUD —Substance Use Disorder State Licensure Program
ZONING DEPARTMENT - Zoning Use Confirmation - Sign off for Local Authorities
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF THE APPLICATION: ❑ Initial Application
❑ Renewal Application
8 Modification -Change in location
Type of Substance Use Disorder
❑Residential /Transitional 0 Outpatient ❑Day Treatment
services being provided:
SECTION B: TO BE COMPLETED BY THE APPLICANT - PHYSICAL SITE LOCATION
Current Name of��gency: SummitStone Health Partners
Address: 114 Bristlecone Dr.
City: Fort Collins
Name of Contact Person for any questions:
Zip: 80524 County: Larimer
Suzanne Lobodzinski or Brooke Lee
Phone: (970) 494-4200 Fax: (970) 484-9380
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY ZONING DEPARTMENT
(this section must be filled out by the proper authority to be considered a valid document)
Zoning Department having jurisdiction: &-IZX df' fOaT L04: /jA,15
The above named facility meets the requirements of the local authority having jurisdiction for the occupancy
based on work outlined above. (If "no", please explain on a separate attachment) ,-YES ❑ NO
Signature:
{/,�1 —/�_ Date:
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Printed Name: lglcas Cx.4sGG> �J Title: �A11W& zav"t-cFa<
Address: vWl & 4 /1O XIZ City: 4x vcc_ Zip: �� 1
Revised 08/21/14