HomeMy WebLinkAbout1809 CHURCHILL CT - APPLICATIONS - 7/19/2019Cltyof Planning, Development, & Transportation Services
®rt liras Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970.416.2740 Fax: 970.224,6134
OVER-THE-COUNTER ER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). XAir 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 ❑ 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.
Application # b 1fDSLiy1i Date i I
For office use only (� LIs
]ob Site Address (required) Value of Construction (labor, materials, profit)
150 6�6ft i (+• Fu ri Co tt,ts CD '5a6 It $iti Ca S
Property Owner Name Address City/State Zip Phone
V,Viezu' RA60 v CA FCd 14524 (97b]231-721A
Applicant Name Address City/State Zip Phone
TrA? ReeklKc- F tCzi(iv,-s Co $05;S
Contractor Address City/State Zip Phone
AMP iI��t S�� 4IGvo FK�M11)(L tIL' � �it• (02 cr{ �i.il�ay C� fJU�aS C1?0j
Contractor City of R. Collins Sales Tax # Are you paying taxes here or by report? ❑ Here 9L.Report
Sales tax number is required by allcontradors. Are you paying with your trust account? KYes 13.b)o
5-a3 i a
Is this a residential or commercial project? Residential ❑ Commercial
If residential, is it: Single 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 50 years of age or more? ❑ Yes O No Ifyes, you may need to conractHistoricPreservation
If this is for a demolition permit, what year was the building constructed?
Description of work -�Ok fj j U go'/e NG, F rvua�r,e e-c r ?.Sfor Q�
_IDS �M rnv,{Cf
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
Electrician m�- l GSA Plumber Mechanical 60,2, 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: _ ^ G
Print Name:�e�1V"Ch� �c16�3 Signature Date ( I
Revision date ZV2017 L•'