HomeMy WebLinkAbout417 N ROOSEVELT AVE - APPLICATIONS - 10/12/2017C iL gat Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
- 281 North College Avenue
Fort Collins, CO 80524 Main: 970.4162740 Fax: 970224.6134
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 # ) Le Date
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
'q -fl_ Ry e e i+ AvenuQ, �-7, Ins C `6t>S�l
Property Owner Name Address City/State Zip Phone
Applicant Name Address City/State Zip Phone
Contractor Address City/State Zip Phone
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wtir d 1 3 7 r>-- >-7-0000
Contractor City of Ft Collins Sales Tax # Are you paying taxes here or by report? �t,�K(Here ❑ Report
ts sales wxnumber required bya#mnbacm1"
rs. Are you paying with your trust account? Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it *10 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 ❑ No If yes, you may need to contact Hrsinric PreservaGan
If this is for a demolition permit, what year was the building constructed?
Description of work eM e<L S c Q 7hcL Sh . n
LJ1iki rxjo'1� Part IU u11) nUIP S-
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List Me company name or arty of Ft Collins license #
Electrician Plumber Mechanical Roofer Other
I hereby acknowledge that I have read this application and state that the above intonnation 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: 1 ii1- r �' L'" \. Signature -� Date �l� fa
ReJ.don date 202017