HomeMy WebLinkAbout6213 SOUTHRIDGE GREENS BLVD - APPLICATIONS - 10/17/2017City of Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.4162740 Fax: 970.224.6134
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 ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information
n'o jn the application. Incomplete applications will not be accepted.
Application # IJ I-1v u `vv Date iol
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
6213
50 C 1
Property Owner Name Address City/State Zip Phone
rbr+ 4011rwa, ca
la tOacan l 9 8 l
Applicant Name Address City/State Zip Phone
Zton F9r4 Ulsm6 40 go R qD -0 3 yj3D
Contractor Address City/State Zip Phone
Lrru c 6l '1 o
Con ractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? Here ❑ Report
Sales tax number is required by all contractors Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? 91 Residential ❑ Commercial
If residential, is it: 51 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 R No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work yveaL. ki rzw tg .f:.f.'P u�1 "A,L4ly 6xvii," 1',,._�!<..�
*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 ofRCCoollllislicense #
, ' ` Waslcra Fi6P
Electriciar(2 Plumber C�6%�� Mechanical Roofer LQ4rC 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:
Print Name:\X>aVW- �1oQ�C�C1y Signature Date \O �'[ - VI
we
Revision date ZWO17