HomeMy WebLinkAbout612 BALSAM LN - APPLICATIONS - 12/18/2018cI"iy GT
Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 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
� on the application. Incomplete applications will not be accepted.
Application # go 1 � Vo S 0 Date Z�! Ff �r -6�-
For office use only
Job Site Address (required) Value of Construction (labor, materials, profit)
61 L i, A t 5c., w, L,^ . rk „, 5 Z wog"
Property Owner Name Address City/State Zip Phone
Fran K Cclz 61L �c> t sc w� Gv%. -fork Cot t;PA5, C0 �05Z6 q10 6a�-6764
Applicant Name Address City/State Zip Phone
T)XV,. C 5WL); 6( / /
Contractor Address City/State Zip Phone
Q; Fe WL 56.sv0 C 3Zw� __60136
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
5alestax number isrequired byall mntractom Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? ❑ Residential ❑ Commercial
If residential, is it: ❑ 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 Ifyes, you mayneed to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work l U ' S,5 . cj Sc�v! cc. CCe ,, r— S� ma&n III s fCA1% dV
5woao Ctcc eov*5
*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 or Ft Collins license #
Electrician Plumber Mechanical Roofer 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: c/
Print Name:T; LJJ i1b,< W " fVCZ Signature
Revision date 2/6I2017