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Community Development & Neighborhood Services
281 N. College Ave Fort Collins, CO 80522
970.221.6760 970.224.6134 - fax
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Community Development & Neighborhood Services
281 N. College Ave Fort Collins, CO 80522
970.221.6760 970.224.6134 - fax
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BUILDING PERMIT APPLICATION
FOR OFFICE USE
APPLICATION NUMBER: APPLICATION DATE:
Job Site Address Unit#
PROPERTY OWNER INFO: (All owner information is required – NOT optional)
Last Name First Name Middle
Street Address City State Zip
Phone # Email
Name of Business (COMMERCIAL USE ONLY)
CONTRACTOR INFO: Company Name
License Holder Name LIC # CERT #
LEGAL INFO:
Subdivision/PUD Filing # Lot # Block # Lot Sq Ft
CONSTRUCTON INFO: Total Building Sq Ft (NOT including basement) Total Garage Sq. Ft.
Residential Sq Ft Commercial Sq Ft # of Stories Bldg Ht # of Dwelling Units
1st Floor Sq Ft 2nd Floor Sq Ft 3rd Floor Sq Ft Unfinished Basement Sq Ft
Finished Basement Sq Ft # of Bedrooms # of Full Baths
¾ Baths ½ Baths # Fireplaces
ENERGY INFORMATION: (CHECK ONE)
ComCheck ܆܆ UA (ResCheck) ܆܆ SPA(Simulated Performance
Alternative) ܆܆ Prescriptive܆܆ ERI(Energy Rating Index) ܆܆
Air Conditioning? YES տտ NO ܆܆
City of Fort Collins Approved Stock Plan # SP0 List Option #s
UTILITIES INFO: Gas տտ Electric ܆܆ Electric Temp. Pedestal Yes ܆܆No ܆܆
Electric Main Breaker Size (Residential Only): 150 amp or less ܆܆ 200 Amp ܆܆ Other տտ
ZONING INFO: (COMMERCIAL USE ONLY)
Proposed Use: (i.e. medical, office, bank, retail, etc.)
For Commercial remodels and tenant finishes, please answer the following questions:
Is the remodel/tenant finishes for an existing or new tenant? (Please check one)
Existing Tenant ܆܆New Tenant ܆܆
If for a new tenant, is this the first tenant to occupy this space?
Yes ܆܆No ܆܆ If not for the initial tenant for this unit, what was the previous use of this tenant space?
Are there any exterior building changes (including mechanical) associated with the work? Yes ܆܆ No ܆܆
If yes, please describe:
COMMUNITY DEVELOPMENT & NEIGHBORHOOD SERVICES
281 N. College Ave. xx Fort Collins, CO 80524 x Phone: 970.416.2740 x www.fcgov.com/building
Job Site Address
PROPERTY OWNER INFO: (A
Finished Basement Sq Ft # of Bedrooms of Full Baths## o
¾ Baths ½ Baths # Fireplaces
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B2101251 2/17/2021
Value of Construction (materials and labor): $
Description of Work:
JOBSITE SUPERVISOR CONTACT INFO: Name Phone
SUBCONTRACTOR INFO: Electrical Mechanical
Plumbing Framing Roofing
Fireplace Solar Other
ASBESTOS STATEMENT DISCLOSURE: In accordance with the State of Colorado Senate Bill 13-152, property owners, applying for a
remodel permit, shall indicate their awareness about their property having been inspected for Asbestos Containing Materials (ACM's).
տ I do not know if an asbestos inspection has been conducted on this property.
տ An asbestos inspection has been conducted on this property on or about (enter date)
տ An asbestos inspection has not been conducted on this property.
Applicant: I hereby acknowledge that I have read this application and state that the above information is correct and agree to
comply with all requirements contained herein and City of Fort Collins ordinances and state laws regulating building construction.
Applicant Signature Type or Print Name
Phone # Email
THIS APPLICATION EXPIRES 180 DAYS FROM APPLICATION DATE
Value of Construction (materials and labor):
Description of Work:
Applicant Signature
Phone #Email
Type or Print Name
SUBCONTRACTOR INFO:
JOBSITE SUPERVISOR CONTACT INFO:
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City of �tCollt�s lkltld,n, S.Nk:41, P08'i, � 21t N' Cot.:·c• A.;e F"" '°''""· coeo�1• �J '�16 740 phOntf 91'0 11-4 bl,� fu
HOMEOWNER AFFIDAVIT
Uww -·-..,,.��,_._.. ---;;;... __ _;..;;;. ... -.) .. _ ol lho .. _.l _
At _____ ...;290=:..I T.:_:e al:,:E:1Y:::•_::C.,,::u�n!...... ___ F.,, C.,,iltlS, cab-.� dodateand _,
lO tho loi-.ng, (p,l,taM Cl>oc/r only f!o ona 11>01 ,w,Ne•t
OPTION 1;
OPTION 2·
D I am/ we are acting on my/ our behalf for !he P\l'PO!le or obllliOlng a buil6ng pe,m� and penionaJly consllUClJng my/ov, home The t,ome IO be oon•INCtod la on 11\o above p,opo,ty """ will be my/our primary R!$ldence. 11v,.., have not pe"""8Uy oonsuucted any other ,_ home$
In lhe Fon Collins Olly llmill "'1th1n Ille palll 2A-month period
QPTION3·
la I am/we ore actlng .,, my/our behalf for Ille PUIJIOSO of ob lalnlng • building pe,mll and pe,sonally cons1rucung an ollerollon or adclnJon 10 myfour house, actlng as our own gen8"11oontrador. The hcvso to be alb!red Is on !ho above proporty and Is my/our pe,aonlll pnmary residence
0 I am/wo ore llcilng on my/our beholl for the purpooe of oblainlng • buijd,ng pe,mtt and pe<sonalty eonslruaing a non-sttuctural altsf8tlon IO my/our attached slngla lamlty dwelllng unit The house to be lllt&rod I• my/our personal •clro•ry lalctonce t am nware that I/We canno1 do any sln.letura� eledrical, plumbing or mechanical worl< and must hire contr&dOrsisuboonlractors who are Q/rronlly licensed and mured with Ille C.ty of Fort Colina
I am/we are p0<$0nally perlGrmlng alt of the wOrl< or hiring City of Fort Colfina licensed trades people. or wrll be oonbnuOusly supe<v!slng unpaid \/Cluntoers (lff Option 3 lor aaached dwelllngs� The worl<"' directly related
to the construction of the above rererenced home.
lfwe understand lhat any pe,son(s) or agent(s) contractod to perform structu ral wood-rrarmng. plumbing. HVAC. electncal or roofing work. MUST BE licensed con1rac1cn in acoordanco w.th the regulation of the City
o( For1 Colm.
I/We undOfStand 11\at failure IO comply wtlh any of the ebove oond1bons may result In revocabon of any perm,ts
nsoaated with the above Pem1il Appllcatlon number, forfeiture ol eny roes lha1 have been cell acted, 1 Stop Worlt Order and potenoally a court summons.
s,g,, In""'-·-o/ ,;-, -
Tho (Qr990lng Affldavll was aCMDW!edged before me on Ihm rz-
l'eu..,'""1 • �,(monll\, year) by C., !5 ,:? lh-"ftO
dayol
c32 27·NOIJl<y Pubhc
B2101251