HomeMy WebLinkAbout4229 BREAKWATER CT - APPLICATIONS - 9/16/2019 (2)'.Jtui�w *
City of
art 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 ❑ Electrical Alteration ❑ Gas Lighter ❑ Gas Log ❑ Heating Unit ❑ Lawn Sprinkler
❑ Mobile Home replacement ❑ Sewer Line ❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove
(must be EPA certified, provide make, model and manufacturer).
Complete all applicable Informationonthe application.
Application #e_ hi "I 1100 `�Q
For office use only
Incomplete applications will not be accepted.
Date
Job Site A dress (required)
Value of Consruction (labor, materials, profit)
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Address
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Phone
Applicant Name
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Address
City/State Zip
Phone Cno
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Con1ancuptractor '^`
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`City/State Zip
Phone Oil-
Contractor City of Ft. Collins Sa Tax #
Sales tax number lsrequired byall contractors
Are you paying taxes here or by report? Here
Are you paying with your trust account? PYes
El Report
❑ No
Is this a residential or � ,crommercial project? ]k 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 If yes, you may need to contactH/storicpreseivation
If this is for a demolition permit, what year was the building constructed?
Description of work
*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 of ft Collins license #
Electrician Plumber Mechanical �1 Roofer—. Other
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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 �M'Cb D
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Print Name: Signature �� 1 1�1.J(y�ate
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