HomeMy WebLinkAbout622 MILLER DR - APPLICATIONS - 7/2/2019 (2)C,C,ltyof Planning, Development, d Transportation Services
art Collins Community Development & Neighborhood Services
281 North College Avenue
Fort Collins, CO 80524 Main: 970 416 2740 F 970
ax 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 ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement eRoofing ❑ 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 # S 1 I �) Lr�-`l S Date
For office use only a
Job Site Address (required)
Gaa M; ller C71—
Value of Construction (labor, materials, profit)
11 L00
Property Owner Name
Address
City/State ZIP
Phone
I -carry �t-( �G to/a,
Boutc(er �1 �
Jac rt Col! i c Q) 00512LL(
6170)920
Applicant Name
Address
City/State Zip
Phone
Nctarn; Orolo�'cz, 3
Gi. 3rdDr
&O K o3
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Contractor
Ar rn _
Address
City/State Zip
Phone
Contractor City of Ft. Collins Sales Tax # Are you paying taxes here or by report? ❑tlere fiRej
Sales tax number isrelquiredbyall contractors. Are you paying with your trust account? R� yes El No ool3lyy�
Is this a residential or cojnmercial project? residential ❑Commercial
If residential, is it: f3Single 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 E(No If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed?
of work
• cmc
*If lawn sprinkler/backflow preventer, must list licensed
D01gecN f
w
If first-time A/C, must list licensed electrician.
Subcontractors: List the company name or City of Ft Collins license #
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 not valid until it has been paid and Issued.
Applicant:
Print Name:_ Nao.►1 i 15iro(o h e z Signature Date 71 /
Revision dale 7/612017