HomeMy WebLinkAbout644 S WASHINGTON AVE - APPLICATIONS - 5/1/2019® & Transportation Services
Planning, Development, p
.-,FOrt CO1lins 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 13 Gas Log
:-"eating 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. Incomplete applications will not be accepted.
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Application # �0181�
For office use only
Date _ 201
Job Site Address (requl'ed) Value of Construction (labor, materials, rofit)
L4 i n F+. 1S D "Z coo
Prope y Owner Napa Address City/State Zip Phone
I ko�n U n n y13 - I Llw�
Applicant Name Address City/State Zip Phone
5 C �; �v�z 97o-?,19 S5
Contractor Address City/State Zip Phone
I u PJ052 976-Z(q 757
Contractor ' y of Ft. ColIQ Sales Tax # Are you paying taxes here or by report? ❑ Here ❑ Report
Sales tax number lsregalredbyaOcontractors. Are you paying with your trust account? ❑ Yes ❑ No
Is this a residential or commercial project? residential ❑ Commercial
If residential, is it: Ingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office t3 Office ❑ Retail
❑ Restaurant ❑ Other (explain) I
Is this building 50 years of age or more? ❑ Yes I o ftyes, jog tnayneed to contact HIstoric Preservation
If this is for a demolition permit, what year was the building constructed?
Description of work G
*If lawn sprinkler/backflow preventer, must fist licensed plumber. If first-time A/C, must,list licensed electrician.
Subcontractors: List the company name or City of Ft GoIllns llmnse OF
Electrician 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 notvaliduntil it has been paid and Issued.
Applicant: 19(m
Print Name: x Signatur i Date Jv
Revis'm date ZWO17
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