HomeMy WebLinkAboutBP & APPLICATIONS - 05-00284 - 4215 N Salem Hwy - New SFR MechanicalZ
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~~ CI1~Y OF REXB URG ~ ~ PERMIT #
BUILDING PERMIT APPLICATION Please complete the entire Application!
19 E MAIN, REXBURG, IT' °' ^ ^^ Tf +hp nnection does not apply fill in NA for non applicable
208-359-3020 X322
PARCEL NUMBER: 05 ~~2 84 •r you)
SUBDIVISION:
Add
i
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d 1 iVt-1C 4317 N Salem K# LOT#
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OWNER: `(-ravc5 Aim, {, e.r~ r CONTACT PHONE # ~(? -~vsZS
PROPERTY ADDRESS: ~ ~ 1 ~ IU - Sc~~ ~ wti '~ ~ ~ct~ ~vY`a .
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: CITY: STATE: ZIP:
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
Work ( )
Cell ( )
CONTRACTOR: {arm r ~ e lam, 1~ P_ r ~-, w~.~S
MAILING ADDRESS: ~ ~ s ~ e ~ ~ ~ ~` S ~_ CITY ~w. ~~ v\ STATES - ZIP y`i
PHONE: Home# 5~~~~~g Work# ~~'~S2S Cell#
EMAIL
ZIP EMAIL
CITY:
FAX
FAX
How many buildings are located on this property? J
Did you recently purchase this property?~:~' Yes (If yes give owner's name)
Is this a lot split? YES (Please bring copy of new legal description of property)
PROPOSED USE: 5
(i.e., Single Family Residence, M
Family, Apartmen s, 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 sweaz 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 conect. 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 day, . i ~~
Signature of Owe
Do you prefer
8 , l5 , os
DATE
5be 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 Reaburg's Acceptance of the plan review fee does not constitute plan approval
3
Please complete the entil~pplication!
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit# (~ ~ -- O ~o - ( Q
Required!!!
MECHANICAL
Mechanical Contractor's Name: ~C'~'~or ~a ~C ~ ~~ r Business Name: ~reh I~ Je h S e ~
Address City ~ State ZOl .- Zip g 3 yL~Z
Contact Phone: ( ) ~ j ~ ~~rj 3 ~~ Business Phone: ( )
Email
Fax
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTU~S & APPLL4NCES COUNT (Single Family Dwelling Only)
~C I Air Conditioner
~- Bath Fan Vents
Range Hood Vents
~ Boiler
Cook Stove Vents
Decorative Gas Fireplaces
Dryer Vents
~ Evaporative Cooler
~ Exhaust or vent ducts
Fuel (gas) piping fixtures or appliance outlets
Furnace
~ Furnace/Air Conditioner Combo
b Heat Pump
~ Incinerator
~~ Pool Heater
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
Space Heater
Unit Heater
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
2 ~3 `f ~-15 -as
Sign r f Licensed Contractor License number Date
Re wired!
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
If the question does .apply fill in NA for non
5