HomeMy WebLinkAbout430 DERRY DR - APPLICATIONS - 12/9/2019FCity of A, Planning, Developmen4 & Transportation Services
ort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.4162740 Fwc 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 ❑ Ptioto-voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stave (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application #,
rwofice rah only
Date December 6, 2019
3ab Site Address (required) Vahm of Construction (labor, materials, profit)
430 Derry Drive, Ft Collins, Colorado 80525 $5957.00
Property Owner Name Address City/State ZIP Phone
Ben Adams 430 Derry Drive Fort Collins, CO 80525 970-305-7378
Applicant Name Address City/State 313 Phone
Christina Evans 1015 lank Lane Ft Co, CO 80524 494-7632
Contractor Address awstata Zipp Phone
Allen Service 1015 Link Lane Ft Co, CO 80524 484-4841
Contractor City of Ft Collins Sales Tax # Are you paying tale here or by report? ❑}lere ❑ Report
saresmxncm:brrkraF redtyaffcmtracmrs Are you paying with your trust account? YWYes ❑ No
10010
Is this a residential or qpmmeroal projecL� Residential ❑ Commercial
If residential, is it V 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 ryw you maynead to contactHisladc Pnewryariron
If this is for a demolition permit, what year was the building constructed?
Description of work PO°m ems"'9 AC mm replace with t Gke AC
'9 lawn sprinkler/bacldlow preventer, must list liaensed plumber. If first-time A/C, must list rrcensed electrician.
Subcontractors List the cnmpanyname or alyoff t CaNrzs!tchww #
6atridan Plumber Medhalloal 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 bmlcfmg construction. I know that a
pemrr-t is not valid until it has been paid and issued.
Applicant: Chr4Wwta Eva u MK*M
PrintName: Signature pate
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