HomeMy WebLinkAboutAPPLICATION - 06-00111 - 1732 Sagebrush Ave - FireplaceC~'~TY OF REXB URG ~ ~j6 00111
BUILDING PERMIT APPLICATION Please ~
19 E MAIN, REXBURG, ID. 83440 If the ques 1732 Sagebrush AVe-Cnty Mech
208-359-3020 X322 _
PARCEL NUMBER: ~ ~ i (VV r wilt EtuviuC tells iur y~u~
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
-~ CONTACT PHONE # ~S~ ' ~/l ~
OWNER NAME:
rROrERTY ADDRESS: 17 a/".~ ~~~ 5~ /~~
PHONE #: Home ( ) ~~-D/6 ~ Work ( ) Cell ( )
CITY: STATE: ZIP:
OWNER MAILING ADDRESS: S.~m`
EMAIL
FAX
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE;
PHONE #: Home ( )
CONTRACTOR: _~
CITY:
FAX
Cell ( )_
-.
~,
STATE ~U ZIP
MAILING ADDRESS: ~~ia Ll ~~" ~~~ ~(/ CITY
PHONE: Home# . '~,~~Work#
EMAIL
How many buildings are located on this property?
Cell# ~% ~-~ ~% ~~
Did you recently purchase this property? No Yes (If yes give owner's name)
Is this a lot split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE:
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify
that I have read this application and state that the information herein is correct and I swear that any information which may hereafter be given by me
in hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply
with all City regulations and State laws relating to the subject matter of this application and hereby authorized representatives of the City to enter
upon the above-me Toned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the
provisions o the 00 International Co e in cases of any false statement or misrepresentation of fact in the application or on the plans on which the
permit or a r al was based. P oid if not started within 180 days. Permit void if work stops for 180 days. ~~
` ~~/~3/
DATE
Signatufe of (3(vner/Applicant
Do you prefer to be contact d by fax, email or phone? Circle One
WARNING -BUILDING PERMIT MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non-refundable and are paid in full at the time of application beginning January 1, 2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval
**Building Permit Fees are due at time of application** **Building Permits are void if you check does not clear**
ZIP EMAIL,
FAX
Work ( )
~ } r
Fleace complete the entire Application! If the question goes riot apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!!
Mechanical Contractor's Name:
Address
Contact Phone: ( )
Email
Business Phone:
Fax
Business Name:
City State
Zip
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL9NCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
Furnace/Air Conditioner Combo Dryer Vents
Heat Pump Range Hood Vents
Air Conditioner Cook Stove Vents
Evaporative Cooler Bath Fan Vents
Unit Heater other similar vents & ducts:
Space Heater
Decorative gas-fired appliance
Incinerator System
Boiler
Pool Heater
Similar fixtures or Appliances
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply Gas Oil Coal Fireplace Electric
Mechanical Sizing Calculations must be submitted with Plans & Application
~~ `~ Point of Delivery must be shown on plans.
:nature of Li ensed Contractor License number Date
MECHANICAL
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho