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CITY OF REXB URG
' BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X326
PARCEL NUMBER:
SUBDIVISION:
UNIT#
BLOCK# LOT#,
OWNER: (j ,~ ,{„ ~,, 9,,, . Jl_ CONTACT PHONE # ~ ~ (a - ~ 7 3
PROPERTY ADDRESS: ~ ( ~ _ r .-~ r1/
PHONE #: Home ( )
Work
Cell
OWNER MAILING ADDRES S: ( ~ , .,~ CITY: STATE:~~ ZIP; g 3 `~ W ~
APPLICANT (If other than owner}
(If applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
MAILING ADDRES S OF APPLICANT
l ~ `t ~ ~ . ~•~ ,Q7~ 'I'~ CITY: ~~ ~,1~,a C- ~ ~'F~TE; T~~ ZIP 83Y0
PHONE #: Home ( ) Work ~~ sa. a. - 8 ~ 87Ce11( )
CONTRACTOR: A ~ ~o~~ ~-~pHONE: Home# Work# Cell#
MAILING ADDRESS: CITY STATE ZIP
How many houses are located on this property?
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-mentioned property for inspections purposes. NOTE: The
building official may revoke a permit on approv issued under the provisions of the 2000 International Code in cases of any false
statement or misreprese tion of fact in the p cation or on the plans on which the permit or approval was based. Permit void if not
started within 180 day .Permit void if wor ops for 180 days.
Signature ofOwner/Applicant
li ~ io.~~
DATE
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 Rezburg'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**
• PERMIT # Q ~ - D OO ~ f
Please complete the entire Application!
If the question does not apply fill in NA for non applicable
Parcel Acres:
FRONT SIDE SIDE BACK
NAME
PROPERTY ADDRESS
SUBDIVISION
Dwelling Units
SETBACKS
Permit#
Front Footage (if applicable)
Storm Water Length
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area Unfuushed Basement area
Second floor/loft area Finished basement area
Third floor/loft axea Garage area
Shed or Barn Carport/Deck (30" above grade)Area
Remodel (Need Estimate) $
PLUMBING
Plumbing Contractor's Name:
Address
Contact Phone: ( }
FIXTURE COUNT
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $
Business Name:
State Zip
Business Phone: ( )
Sprinklers
Tub/Showers
ToiletlUrinal
Water Heater
Water Softener
(Commercial Only)
Signature of Contractor License number Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
2
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m~c~vic~ -/ ~ ~ 63~~.~~ ~-~.-~
Mechanical Contractor's Name: C,.¢. v~ ~ (~'- ~p ~-~. Business Name: r
Address (~ 7 ~ ~ , g ( Q(~ a ~~ a ~2a ~~t~e ~ Zip 8 ~ 4~ O
Contact Phone: ( ) Business Phone: (~p~ ~a ~ ~~ ~ ~
FIXT URES ~ APPLIANCES
Furnace
.. ~`~'
Furnace-Air Conditioner
Combination
Heat Pump
Air Conditioner
Evaporative Cooler
Pool Heater
EXHUAST & VENTILATION
Dryer Vents _
Range Hood Vents
Fuel Gas Pipe of Outlets)
Signature of Contractor
License number
~-~-oS-
Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
WATER METER COUNT
WATER METER SIZE
HEAT (Circle all that ap as Oil Coal Fire lace Electric
Unit Heater
Decorative Gas-Fired
Appliance
Space Heater
Incinerator
Broiler
Cook Stove Vents
Bath Fan Vents
Mechanical Estimate $ (Commercial
Only)
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