HomeMy WebLinkAbout4640 WITHERS DR - APPLICATIONS - 4/2/2019 (2)City of planning, Developmen4 & Transportation Services
176rt Cd1in$ 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
❑ Pernolition (interior non-structural) ❑ Electrical Afteration (not service change) ❑ Gas Lighter ❑ Gas Log
B0Heating 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 inforrm�adon on the application. Incomplete applications will not be accepted.
Application # n V I Date April 2, 2019
For dhke me oMy
Sob Site Address (hVi&ed) Value of Construction (labor, materials, profit)
4640 Withers Drive, Fort Collins, CO 80524 $6750.00
Property Owner Name Address WState Zip Phone
Christie Rogers 4640 Withers Dr 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 awstatn 21pp Phone
Allen Service 1015 Link Lane Ft Co, CO 80524 484-4841
Contractor City of FL Collins Sales Tax # Are you paying taxes here or by report? Ojiere ❑ Report
Saks &rmvdvr&mgtnsedbyaucmtracbm Are you paying with your trust account? VYes ❑ No
10010
is this a residential or qpnmerdal project? Residential ❑ Commercial
If residential, is it: "Msingle Famay Detached ❑ Cando/lovmhome (single family attached) ❑ Duplm(
❑ Multifamily (apartmert) ❑ Garage
if commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hote1/Notd ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
is this building 50 years of age or more? ❑ Yes ❑ No Ifyasy you maynePd t0 m7tAthi t%*Pn�n
if this is for a demolition permit, what year was the building const udW7
Description of work Rr a existing fi"10Ce wA replace with like me ram,"-"
r
*If lawn sprinlder/baddlaw preventer, must list licensed plumber. If first-time A/C, must fist licensed elecbidan.
subcontractors-. List the =Wnyname or OW offr C60w hbw= #
Hadrian Plumber Media W Roma Other
I hereby admowledge 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 budding construction. I know that a
permit is not valid until it has been paid and issued.
Pn�tare:Chri rca.>vcivtb signature hhda,rl E . I.JVan. 412J19.
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