HomeMy WebLinkAbout410 E LAKE ST - APPLICATIONS - 5/20/2019.r yoi E Planning., DeveBopment. A Transportation Services
_.F®r$ Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224.6134
OVER-THE-COUNTER PERNTS 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 XWood/Re4et Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # )� I "� () �LA I
For office use only
Date
Sob Site Address (required) Value of Construction (labor, materials, profit)
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Property Owner Name Address City/State Zip Phone
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Applicant Name Address City/State - Phone Cg7a) 0A-51 boS_ F:E7,✓LL— Oz�,i I uaa,
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Cpntractorn Address J� City/State t Zip Phone ��'7�
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Contractor City cif Ft. Collins Sales Tax # Are you paying taxes here or by report�� Jere ❑ Report
Sales[axnu er sr /red&t contractors Are you paying with your trust account. ❑ Yes 'LYNo
Is this a residential or commercial project? . Residential ❑ Commercial
If residential, is it: ASingle Family Detached ❑ Condo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building SO years of age or more? ❑ Yes)( No Ifyes, you may need to contact HlstoricPreservation
If this is for a demolition permit, what year was the building constructed?
Description of work14_)4zc i.CJQ
/ia,�ii'7 I-� u�va tii-5P_ft �� an 2X- J m��a�ry �'/�a/�e�•
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A1C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins //tense #
Electridan 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 not valid until it has been paid and issued.
Applicant: ti. A��\ Date Slf2 r
Print mame' /l.1'i1 i P. - - _ L Signature
Revision date 21612017