HomeMy WebLinkAbout145 3RD ST - APPLICATIONS - 11/1/2018Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 N13in: 570 4.16.2740 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 ORoofing ❑ 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 # S� �g c)q(0 D3 Date 11-1—1 a
For ofce use only
Job 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
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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 Z Report
Sales tax number Is required by all contactors Are you paying with your trust account? Ja Yes ❑ No
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: Jd'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
*If lawn sprinkler/backflow preventer, mQt list licensed plumber. If first-time A/C, must list licensed electrician
Subcontractors: List the company name or Oty of Ft Collins license
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Electrician Plumber Mechanical Roofer l LkL LL 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: q p�
Print Name:F Signature Date
Revision date M12017