HomeMy WebLinkAbout4640 WITHERS DR - APPLICATIONS - 4/2/2019 (3)City of Planning, Developmen4 & Transportation Services
Fort CO!lins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.4162740 Fax 970224.6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply):OrAir Conditioning
❑ Demolition (interior nonstructural) ❑ 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 ❑ WoodfPellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the
application. Incomplete applications will not be accepted.
Application # � nf
l t 0 Z Z0 Date April 2, 2019
For office rem only
Job Site Address (mqubad) Value of Construction (labor, materials, profit)
4640 Withers Drive, Fort Collins, CO 80524 $8271.00
Property Owner Name Address City/babe ZIP Phone
Christie Rogers 4640 Withers br Ft Collins, CO 80524 970-402-5036
Applicant Name Address City/State Zip Phone
Christina Evans 1015 Link Lane Ft Co, CO 80524 494-7632
Contractor Address (3ty/Slate Zip Phone
Allen Service 1015 Link Lane Ft Co, CO 805Z4 484-4841
Contractor City of FL Collins Sales Tax 4 Are you paying taxes here or by report? ❑,Mere ❑ Report
5�ifttax wjrbff&Aglriredbya0anhariwx Are you paying With your triaaccount? VYes ❑ No
10010
Is this a residential or mriumal project? IdlResideilitial ❑ Commercial
If residential, is fi V Single Family Detached ❑ Condo/toirmhonre (single family attached) ❑ Duplex
❑ Multifamily (apartrnent) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Ofiice 17 Retail
❑ Restaurant ❑ Other (explain)
Is this building 5o years of age or more? O Yes ❑ No Ifyas, yaw may need to wnt3ttff4o c Arnserrr hkw
If this is for a demolition permit, what year was the building constructed?
Description of work R 1 w "61irg AC ®.d replo with like. AC
*If lawn sprinkler/baddiDw preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors, W ffie yname erLRyoffraffisixerrw 0
Flecft Plumber MechanM Rooter other
I hereby admoWedge that I have read this application and stale that the above information is complete and correct. I agree to
comply with all requlremmits contained herein and city ordinances and stator: laws regulating building construction. I know that a
permit is not valid until it has been paid and issued. ►/�q �/j Applicant- Ch+i4t6vawS C � wl /1/�P✓dU �� 1
Print Name: Signature Date
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