HomeMy WebLinkAbout4640 WITHERS DR - APPLICATIONS - 4/2/2019City of►,. , Planning, Development & Transportation Services
Fort W[II�S Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 8057A 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) ❑ Becfrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit .7 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 Informati(on on the application. Incomplete applications will not be accepted.
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Application # 5 v zcg� Date April 2, 2019
For otrixLma*
lob Site Address &equusd) Value of Construction (labor, materials, profit)
4640 Withers Drive, Fort Collins, CO 80524 $6565.00
Property Owner Name Address City/Slate ZIP Phone
Christie Rogers 4640 Withers Drive Ft Collins, CO 80524 970-402-5036
Applicant Name Address aty/State TiP Phone
Christina Evans 1015 Link Lane Ft Co, CO 80524 494-7632
ContraC6or Address City/State Zip Phone
Allen 5ervice 1015 Link Lane Ft Co, CO 80524 484-4841
Contracbor t]fy of Ft Collins Sales Tax 8 Are you paying taxes here or by report? ❑ ere ❑ Report
Wwtar wnil bffh;relrmrrlbyalm traan s Are you paying with your tent account? IFYes ❑ No
10010
is this a residential or mmercial project? Residential ❑ Commercial
If residential, is it or
Family Detached ❑ t'do/eownhome (single family attached) f] Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hohd/Mote! ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or mare? ❑ Yes ❑ No B' ew you mayneed to contact H&Wc Heserva&n
If this is for a demolition permit, what year was the building mnstruded?
Description of work
*If lawn sprinkler/bacidiow preventer, must list licensed plumber. If first-time A/C, must fist licensed electrician.
Subcontractors: List Bhec mLanyeameorQyoffrCatr Nhbmw0
Flectr Plumber Mechanical Roarer Other
I hereby advrowledge that I have read this application and state that the above information is complete and corm I agree to
comply with all requirements contained hereln and city ordinances and state laws regulating bucldag construction. I know that a
permit is not valid until it has been paid and issued,
Applicant: Chr4stC ta.i:vaws
Print Name: Signature ! P A r Date
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