HomeMy WebLinkAboutAPPLICATION - 05-00194 - 502 S 5th W - Lawn SprinklersCITY OF REXB URG
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X322
PARCEL NUMBER:
( We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
OWNER: (Z'~~h4~~~~0~~ 11 ~-~(~}_CONTACT PHONE # ~~ (~ • ~ ~ ~2
PROPERTY ADDRESS: `7 ~
FAX
PHONE #: Home (Zog) ~5 (n• ~ (~(2 Work (~0) 3~ (• 5?0 ~ Cell ( ) ~ 5 ~ ~ ~ 2S
OWNER MAILING ADDRESS: ~(~ Z ~v Cj W _ CITY: STATE~ZIP: ~3~-a
EMAIL
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
CITY:
STATE; ZIP EMAIL
PHONE #: Home
Work
FAX
Cell
CONTRACTOR:
MAILING ADDRESS: ~ ~ (~ ~ O • ~Q`1-~-21~ CITY r STATE ~ ZIP
PHONE: Home# ~~ ~ l 3~1 Work# Cell# ~~ ~ $T-,~ Z
EMAIL FAX
How many buildings 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,
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 approval issued under the
provisions of the 2000 International Code in cases of any false statement or misrepresentation of fact in the application or on the plans on which the
permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
/ /
Signature of Owner/Applicant DATE
Do you prefer to be contacted 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**
PERMIT #
Please com lete th ~ tire A lication!
P pp
If the question does not apply fill in NA for non applicable
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