HomeMy WebLinkAboutAPPLICATION, BP - 05-00293 - 3467 W 2000 N - New SFR MechanicalZ
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C,~~~'Y OF REXB URG
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X322
PARCEL NUMBER:
SUBDIVISION:
(Addressing is based on the information - n
PERMIT #
Please complete the entire Application!
If the question does not apply fill in NA for non applicable
( We will provide this for you)
UNIT# BLOCK# LOT#
lust be accurate)
_.
OWNER: ~ . _ - _
CONTACT PHONE # <- - ~ "
~ - - _>-
PROPERTY ADDRESS: ~I~ ~_ `~) ~ ..; ~~ C_ yC_.
PHONE #: Home (~i,b) ~~~~ ( ~ l C`> ~,i ~.
OWNER MAILING ADDRESS:
EMAIL
CITY:
Work (~~s) 3 ~ ~-.- ~=~1 ~ ~
STATE: ZIP:
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
STATE; ZIP EMAIL
PHONE #: Home
CITY:
FAX
Work ( )
05 00293 P
CONTRACTOR:
MAILING ADDRESS:
PHONE: Home#
EMAIL
Work#
HVAC Madison
FAX
Cell
Janson 3457 W 2000 N
How many buildings are located on this property? ~ -~ ~'1 C'
__.
Did you recently purchase this property? No ~es'(If yes give owner's name
Is this a lot split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE ~ ~ . r.a ~ ~ - ~ t~, .; ~-i ~, ~~::`,r ~.-~~:" ; ,
(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 sweaz 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.
~. ~:1_ i`
Signature df Owner/App is t J -~----,. DATE
Do you prefer to be contacted by fax, email oiT`phone?' Circle One
WARNING -BUILDING PERIVII'I"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
FAX
Phase complete the entil~pplication! If the question does ~pply fill in NA for non
applicable
NAME
PROPERTY ADDRESS Permit#
SUBDIVISION
Required!!!
MECHANICAL
Mechanical Contractor's Name: Business Name:
Address City State
Contact Phone:
Email
Business Phone:
Fax
Zip,
~ Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLL4NCES COUNT (Single Family Dwelling Only)
ti (~, Air Conditioner
`~ Bath Fan Vents
Range Hood Vents
Boiler
Cook Stove Vents
r Decorative Gas Fireplaces
Dryer Vents
Evaporative Cooler
_ Exhaust or vent ducts
~' Fuel (gas) piping fixtures or ap~lia_nc_e out _1
~_ Furnace
Furnace/Air Conditioner Combo
Heat Pump
Incinerator
Pool Heater
Heat (Circle all that apply) , Ga~ 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.
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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