HomeMy WebLinkAbout4367 WESTBROOKE CT - APPLICATIONS - 12/26/2017City of
Fort Collins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 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). ❑ 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.
� l Application # �ow Date
L For oe use only `
Job Site Address (required)
Value of Construction (labor, materials, profit)
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Property Owner Name
Address
City/State -' - c: Zip S-�'S . Phone
Applicant Name fic4ica n e -e J.
Address
City/StAe�`Uo) oso r Zip 6 !S�61 Phone ej �r
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Contractor
Address
City/State Zip Phone
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report? ❑ Here ❑ Report
Sates tax number lsrequired byall conbactors.
Are you paying with your trust account? ❑ Yes ❑ No
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Is this a residential or commercial project? `&Residential ❑ Commercial
If residential, is it: r' EISingle 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 -.El-No' if yes, you may need to contact Historic Preservation
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 work
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*If lawn
preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or Gty of Ft Collins license #
Electrician Plumber Mechanical Roofer C2 r� Omer -
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: I ^i
Print Name: �%1� < 4 (� L- n r I . Signature -t - - C Date _ �"