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CITY OF REXB URG ~ PERMIT #
BUILDING PERMIT APPLICATION Please complete 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: w ~ ONTACT PHONE # ?~5q -GJ5~0
PROPERTY ADDRESS: y~ ~l/ ~ s~ N ~xbttrq
PHONE #: Home ((~ ~-~ 5~ Work ( ) Cell ( )
OWNER MAILING ADDRESS: `~ 2 W ~ g~/V CITY: b ~ STATE:~ZIP:~?3~~p
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
STA
PHONE #: Home
CITY:
ZIP EMAIL
Work
Cell
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: ~ J Ar L° - ~ ~.v~.lv~~ v
'(i.e., Single Family Residence, Multi Family,
FAX
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.
of
~i~i ~S
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**
Please complete the entir Application! If the question does apply fill in NA for non
applicable
NAME °~ S
PROPERTY ADDRESS 4 ~^(q/ (S ~/ Permit#
SUBDIVISION
Required!!! MECHANICAL
Mechanical Contractor's Name: Business Name:
Address City State Zip
Contact Phone: ( ) Business Phone: ( )
~i Email Fax
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL9NCES COUNT (Single Family Dwelling Only)
Furnace ~_ Exhaust or Vent Ducts
Furnace/Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
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
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Heat (Circle all that appl ,Gas Oil Coal Fireplace Electric
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature of Licensed Contractor License number Date
Required!
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
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