HomeMy WebLinkAbout140 FISHBACK AVE - APPLICATIONS - 12/4/2018City of
M
Planning,, Development tr Transportation
904 KI !`..Ii....n Avn A n 0..., coo
134
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical AtteraUon (not se ce change) ❑ Gas Lighter ❑ Gas Log
❑ Heaf Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement Roofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet S e must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. incomplete applications will not be accepted.
Applicatjon #y��� Co b 55 Date
Foronice use only
Job Site Address (requl
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}Value of Construction pabor, materials, profit)
property Owner Named
Address
City/State Zip
Phone
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Applicant Name
dress
City/State Zip
Phone
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Contractor Address
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Ci /state Zip
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Phone
20 (011
Contractor City of Ft. Collins Sales Tax #
Are you paying tax here or by report? ❑ Here
❑ Report
by all mn&actom
Are you paying with your trust account? ❑ Yes
❑ No
Is this a residential or ogmmercial project? Resfdentlal ❑ Commercial
If residential, is it 1ngie Family Detach ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motef ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? i] Yes O No If yes, you may need to contmtHLston`cc Preservation
If this is for a demolition permit, what year was the building constructed?
Ifprior to 1975, you wi/l need an asbestos assessment to subn7k with this aAa6iwdon.
of work
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*If lawn spdnkler/baddlow prevenber, must list licensed plumber. If first-time A/C, must list licensed efectridan.
Subcontractors: Ust Me company name or City of Ft Collft ffwnw #
ElecMdan Plumber Machanlcal Roofer Other
I hereby acknowledge that I have read this application and state that the above inform�on is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regul ng building construction. I know that a
permit Is not vajid until R has been paid and issued.
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Applicant: ` ,, y�}, - sm�Date
Print Name: rt4-`r)i� S�ignature a0"-6-