HomeMy WebLinkAbout602 KEENESBURG CT - APPLICATIONS - 4/13/2017APR/11/2017/TUE 10:26 AM FAX No, P,005
City of Planning, Development, & Transportation Services
Fort Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 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 ❑ Roofing ❑ 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.
Application # 151 40 iga(o
rvr office use only
Incomplete applications will not
be accepted.
Date
Job Site Address (required) value of Construction (la or, materials, profit)
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Property Owner Name J Address City/State Zip Phone
Applicant Name Address City/State Zip Phone
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Contractor Address City/State Zip Phone
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Contractor City of R. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales lax number isrepulred(byyyrg1trac Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial ercciia`l project? ❑ 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 CI Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes ❑ No If yes, you may need m contact N$bdc pre_servadon
If this is for a demolition permit, what year was the building constructed?
D Scr' tion of wo I '� t1)4
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*If lawn sprinkler/back low preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: Lis? Me company name or aty of Collins license 0
Etectndan Plumber Mechanical 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 building construction. I know that a
permit is notf valid until it has been paid and Issued.
Applicant: I/ r�1 I' }o l/
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Print Name;
R"Von Data?J W