HomeMy WebLinkAboutApplicationLiar• fteld County
Community Development Department
108 8`" Street, suite 401
Glenwood springs, CO 8161)1
(970)945-8212
�ieidzount co, ov
_ iON.
TYPE
Damoiitlon
Multt_i amlfy.. _ Gas Pin . _ ---
_ Camsnerciaf/ -" -._ _ _•....�_.._.__.. ----� C�"1 Reroof ._,.__..___w,-
Man_ufartured Horne.�Sfn�ie or Mu4t1-Leve1�... �r� � ..;
Residential (5F, D
4up�oA} n MUM SiXE DF.7� F F!E7
� ACCeS5P1�1 dWelilnq_ - _ ..ES
.....
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,l 1 r- g5- -71, 5
• � LJ � ��'� � Phone: {}�i �'/ ��•
Property Owner: !t� r i.
ol
Mailing Address a 3 (7 �$ 4
r 1� wiaa r•
Email Address' _ - jr
_ _ .. _ -.- - ._. _ —.�_. _...._ - - • ---- __ _._..._._ _ �._
P >. &I'*V
Phone:Contractor j
Mailing Address: _ 4 �i t' ( r (oil '
s Email Address:
_ 10
D cribeWork: C
[,flit
j lob Address: exlee►vT i
! Assessor's Parcel Number: I
i Sub. Lot Block !
Gas Pipe Length/ Diameter: �' 1
Appliances Serviced By Gas Line (list all,udet.ETU):
i
Class of Work: ':nNew T -❑ Alteration _ ^�Addition
Type of Heat: `Natural Gas Propane
NOTICE . R H ' ' the owner of the property, described above,
Authority. This application for a Building Permit must be signed by signed hY
or h authorized agent. o the signature below is not that of the owner, a separate letter of authority, g
the dwner, must fie provided with this Application. ert for
Legal Access. A Building Permit cannot he issued without proof of legal and adequate access to the prop Y
purposes of inspections by the Building Division. pWTS Permit,
i O er P r its. Multiple separate permits may be required: (i] State Electrical tai Permit, {2] County
(3) another permit required for use on the property identified above, e.g. State or County Highway) Road Access
or a State Wastewater Discharge Permit.
ull and `Void P_�.r_A [3ulIwaric is suspended aroid if the work authorized is not abandoned for a period of 18U days after days
carnmencement
i of the date of issuance and f
i hereby certify that I have read this Application and that the information contained above is true and correct. I
I understand that the Building Division accepts the Application, along with the plans and specifications and other
i data submitted by me or as to accracy. Assuming
on my behalf (Submittals), based apvn Build rcertiig Permit t will beussued granting
completeness of the submittals and approval of this App
permission to me, as owner, to construct the structure(s) and Facilities detailed on the submittals reviewed ll
by
I the Building Division. In consideration of the issuance of the Building Permit, i agree that 1 and my agents
i comply with provisions of any federal, state or local law regulating the work and the Gaa�owled a that theld County
Code, OWTS regulations and applicable land use regulations (County Regulation(s)]. g
Building Permit may be suspended or revoked, upon notice from the County, If the location, construction or use
of the structure(s) and faciliiy(les), described above, are not in compliance with County Regulation(s) or any
other applicable law.
i I hereby grant permission to the Building Division to enter the property, described above, to inspect the work.
I further acknowledge that the issuance of the Building Permit does not prevent the Building Official from: (1]
i requiring the correction of errors in the submittals, If any, discovered after issuance; or (2) stopping
I construction or use of the structure(s) or facility(ies) if such is in violation of County Regulation(s) or any other
{ applicable law. Review of this Application, including submittals, and Inspections of the work by the Building
Division do not constitute an acceptance of responsibility or liability by the County of errors, omissions or
discrepancies. As the Owner, I acknowledge that responsibility for compliance with federal, state and local laws
and County Regulations rest with me and my authorized agents, Including without limitation my architect
designer, engineer and/ or builder.
I he acknowledge that I have read and understand the Notice and Certification above, as well as,
have provided the required information which is col' ect and accurate to the best of my knowledge.
# -
Property Owner Print a Sign Date
OFF[CI.AL USE 014LY � r"
Special Conditions
Adjusted Valuation:
N/A
Permit Fee
Misc. Fees:
Total Fees: v
L00
Fees Paid:
tcri
Balance Due:
SP No: nn
�i�
M
BUILDING / PLANNING DIVISID : y/ i" '
Signed Approval Date