HomeMy WebLinkAbout6227 CLYMER CIR - APPLICATIONS - 12/22/2016Cityof ( Planning, Development &,Transportation
} 281 N. College Ave 'P O. Box.580
- dr C®ltins. Fort Collins, CO. 80524
Phone 970-416-2740 Fax 224 6134 : ;
This, application ls'to;be used to apply for the following permits only (check all that apply),.❑,Air Conditioning
❑ [7emolition.(int`erior..non structural) {7. Electrical Alteration (not service change) ❑Gas Lighter _, ❑Gas Log
El Heating Unit ❑Lawn Sp`rinkler,❑ Mobile Home replacement. ❑.Roofing , 11 Sewer Liner ❑.Photo -voltaic
❑ Ventilation; ❑:Water Heater 0,Water Line . ❑ Wood/Pel let, Stove (must.be EPA certified, provide'niak6; model and
manufacturer). •''
Complete all applicable information on the application. Incomplete applications will not ;be.accepted.
APPiication # I `� O +. Date /L-22-1(e
- - Fpr o>Yce us'e only ... - ..
,Job Site Address (required) ;
Value of Construction (labor, materials, profit)
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Property Owner Name Address
city/State Zio:. 'Pho
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Applicant 4ame Ad ress
City/State Zip Phone, .,
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'Contractor ,' Address City/State Zip ' ` Phone
Sr10; l�,r bid' Solrt�aJ3 ttoli" (,. Iwlr)lr<J��
`77 b.7 lo(o'.i 3 77
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Contractor City of, Ft. Coilins5ales Tax:#
Are you paying taxes here or by report? ❑ Here Report
Sales taxn'uf �t�erlsrerltiredbya!lmntractors i
Are you paying With your trust account? ❑Yes ' No:
Is this a residential or commercial protect? Residential; ❑Commercial
If, residential; is it:i �5ingie Family Detadied ❑ Condo/townhome (single. family attached) 0 Duplex
0 Muitifamily'(apa`rtment)- ❑ Garage
If comrnerciali is it: 13 Bank• ❑ Bar ❑ Church .❑ Hotel/Motel ❑ Medical.office ❑ Office ❑,Retail
❑ Restaurant ❑ Other (explain)
Is this building 501years of age or more? Cl Ycs ❑ No, If yes, you may need to contact tlistotrcPreservatlo,n
If this is fora`demolition permit, what year was the building constructed?
If prior to 197.5, you wi%/needan, asbestos ass ssment to, submit :with this application.
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Description of work �2;Ol%1 Gc>" S'� ��J �/� c I JAIPJ �s►91��
y
*If lawn sprinklerlbackflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
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Subcontractors ruist the company name or G'ty ofFt Collins license a
Electrician I' Plumber (b _ Mechanical Roofer tither"
Ihereby acknowledge. that I have read this applicatioh`and state that the above information is complete and correct. I agree to
comply -with all requirements,ointained herein and city ordinances and state laws regulating building construction. I know that a
permit is not.valid'untit it has been paid and issued.
Applicant:. I
Print Name:''i.re-
Signatur _ Date
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