HomeMy WebLinkAbout4743 WESTBURY DR - APPLICATIONS - 1/30/2019Cityof & Transportation Services OZ
Planning, Development, p
�t 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 serves change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement VRoofing ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable informationWO
nthe application.
Application # )J fl 00 OLA
For ofce use only
Incomplete applications will not be accepted.
Date 1 av `")
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lob Site Address (required) Value of Construction (labor, materials, profit)
Property Owner Name Address City/State Zip Phone
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Applicant Name Address City/State Zip Phone
Contractor Addre City/State Zip Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here �Re ort
sales tax number is required by all contractors Are you paying with your trust account? ❑ Yes b'" 0
Is this a residential or com��rrcial project? Residential ❑ Commercial
If residential, is it: El ngle 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 ye
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*If lawn spniKler/backflow preventer, must list licensed plum'trer. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license # Nllj'9—
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: > /�
Print Name: [_S�/vita L4)s4ot1C-76„ Signature 6�5vt/✓�Date / b j
Revision date 216/2017