HomeMy WebLinkAbout430 DERRY DR - APPLICATIONS - 12/9/2019 (2)City of�+Panning, Development & Transportation Services
j�F0t Cdllns Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.4162740 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 tine ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable Infonination on the application. Incomplete applications will not be accepted.
Application #,
Irora ine tse oNy
Date December 6, 2019
Sob Site Address (required) Value of Construction (tabor, materials, profit)
430 Derry Drive , Ft Collins, Colorado 80525 $4750.00
Property Owner Name Address Olty/State ZIP Phone
Ben Adams 430 Derry Drive Fort Collins, CO 80525 970-305-7378
Applicant Name Address City/State Zip Phone
Christina Evans 1015 Link Lane Ft Co, CO 80524 494-7632
Contractor Address Clty/State Zipp Phone
Allen Service 1015 Link Lane Ft Co, CO 80524 484-4841
Contr-actor City of FL Collins Sales Tax # Are you paying taxes here or by report? ❑ fiere ❑ Report
-WeFtar=nbff L-reqkedbyallmnbactam Are you paying with your trust account? IJFYes ❑ No
10010
Is this a residential o*a] project? Residential 0 Commercial
If residential, is it `0 Single Family Detached ❑ ODndo/townhome (single family attached) ❑ Duplex
❑ Muttifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Moth ❑ Medical office I] Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ ko ryes. you mayneed to contatttf5tur c Preswmbon
If this is for a demolition pennit, what year was the building constructed?
Description of work p� exishfuj r,°,ac` aW replace with new kke Fumo
*If lawn spdnkler/hacidlow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors W MecompanynameoraWafftCognshinwse#
Electrician Plumber Medea lm Roofer Other
I hereby acknowledge that I have read this application and state that the above infatuation is complete and correct I agree to
comply with all requirement contained herein and city ordinances and state laws regulating building cmhstrhxtion. I know that a
permit is not valid until it has been paid and issued. y}
Apptcarrt: Christwhc+ Fvand �r fqw Nam a w paw f 24 l I
Print Name: Signature
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