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C>1 ~'Y OF REXB UR PERMI~ ,
BUILDING PERMIT APP CATION Please comple~e the entire Application!
19 E MAIN, REXBURG, ID. 83440 If the question does not apply fill in NA for non applicable
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: ~Qm~e.:f /-f •~ f~v/G~+.l ~vRa~~~ CONTACT PHONE # ;lo ~ ,~~~ .5"S'.S`®
PROPERTY ADDRESS: J5"0 S f s~ ~ 6°l~e~ ~~ '~
PHONE #: Home (~a8) .3 s"(~ ~'S5 o Work ( ) /~ ~¢ Cell ( ) t~ /¢
OWNER MAILING ADDRESS: /,/(a ,$ /5~ ~ CITY: ~L e~dcrf~' STATE:~ZIP: 83~~
EMAIL ~ 1/ ~'
AX ~ fJ-
APPLICANT: (If other than owner)~~( Q.
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS ~!~} CITY: N~-
STATE; ~((,¢ ZIP ~/ /{- EMAIL
PHONE #: Home ( ) .~ ~4- Work
FAX F! v7
~l r4 Cell ( )~
CONTRACTOR:
MAILING ADDRESS:
PHONE: Home#
EMAIL
Work#
FAX
CITY
Cell#
STATE ZIP
How many buildings are located on this property? r~- FIe~, 5fvrr~-fie s~-~d
Did you recently purchase this property? ~No Yes (If yes give owner's name)
Is this a lot split? ~ YES (Please bring copy of new legal description of property)
PROPOSED USE: ~ ~/~-r~i~~( e-~-~S
(i.e., Single Family Residence, Multi Family, App
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 heazings 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.
~P-~~/ Caw--~. l l
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
3
, ~ **Building Permit Fees are due at time of application** **Building Permits are void if you check does not clear**
Please complete ~ entire Application!
If the question does not apply fill in NA for non applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Dwelling Units:
SETBACKS
FRONT SIDE
SIDE
BACK
Permit#
Remodeling Your Building/Home (need Estimate) $ ~ . ~~~
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area Unfinished Basement area it//~-
Second floor/loft area .~J /~ Finished basement area
Third floor/loft area N f~ Garage area ~/ ~
Shed or Barn Carport/Deck (30" above grade)Area ~/~
Water Meter Count:
Water Meter Size:
Required!!!
PLUMBING
Plumbing Contractor's Name: uSSe(/ Gt('~~Q`~'~` Business Name: ~ aSFQC/' (~~¢wc.C,
Address 1 ~3 ((o /~ l (S~ L City .~, F State Zip $3Y0
Contact Phone:
Email
~~~o' d l B(~ Business Phone: ( )
FIXTURE COUNT (including roughed t"rxturesl
~1 1 Clothes Washing Machine
r-I ~- Dishwasher
N R- Floor Drain
/~R Garbage Disposal
Fax ~'3$-73 rZ
~~ Sprinklers
~ /Showers
~ Toiled
/tl a Water Heater
~t /~ Hot Tub/Spa ~/~ Water Softener
Sinks
( avatories, kitchens, ~f
Plumbing Estimate $ 3 ~~~ O'er (Commercial Only)
~l w~e.QSt i~~.~" C (~ ~f 3 ~ ~ L~ d .
Required! Signature of Licensed Contractor License number Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
Parcel Acres:
4