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CI~'Y OF REXB URG BUILDING PERMIT APPLIC~ON 19 E MAIN, REXBURG, ID. 83440 208-359-3020 X322 PARCEL NUMBER: ~,., -~ (( CONTACT PHONE # ~ L - os ~ ,-' S' Ala -~3~' Work ( ) ~/ (b ~ ~3~o Cell ( ) Sf ~- b`~a SUBDIVISION: UNIT# BLOCK# LOT# (Addressing is based on the information -must be accurate) PROPERTY ADDRESS PHONE #: Home OWNER MAILING ADDRESS: EMAIL FAX STATE: ZIP: APPLICANT (If other than owner) (Applicant if other than owner_ a ~+a+a...,,--` - (p9 ~ f ~ ~3 _ds ~~ APPLICANT INFORM ~, STATE; PHONE #: Home ( )_ ( We will provide this for you) CITY: ~a~~ CONTRACTOR: ~~.d ~ ~ Q~ ~~~ ~ ~ MAILING ADDRESS: PHONE: Home# EMAIL Work# How many buildings are located on this property? -~-~~z- j Did you recently purchase this property? No es If yes give owner's name) S~1C~ S Is this a lot split~~ YES (Please bring copy of new legal description of property) PROPOSED USE: ~ (i.e., Single Family Residence, Multi FAX 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 herea8er 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 cas 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 ' n started within 180 days. Permit void if work stops for 180 days. ~ N ; /~/ 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 # ~~"`°9. Please complete ~ entire Application! If the question does not apply fill in NA for non applicable to act as agent for owner must accompany this application.) CITY: FAX Cell ( ) CITY STATE ZIP Cell# s Please complete the~tire Application! If the question does not apply fill in NA for non applicable NAME ~~ S 1~ ~-~ o D ~„ C~: rC~ ~ ~ Tc~ Permit# PROPERTY ADDRESS 3 lcEe r\ ~ ~t~ W ~ ~ SUBDIVISION '~~' ~,~ ~r~K ~5~~~5 Dwelling Units: Parcel Acres: SETBACKS FRONT SIDE SIDE BACK Remodeling Your Building/Home (need Estimate) $ SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building) First Floor Area Second floor/loft area Third floor/loft area Shed or Barn Unfinished Basement area Finished basement area Garage area ,~(1,` k ~ ~; Carport/Deck (30" above grade)Area Water Meter Count: qui~ed!!! PL RING Plumbing Con ctor's Name: Address Contact Phone: ( ) Email City Business Phone: Fax State Zip, Clothes Washing Machine Sprinklers Dishwasher Tub/Showers Floor Drain Toilet/LJrinal Garbage Disposal Water Heater Hot Tub/Spa Wa Softens Sinks (Lavatories, kitchens, bar, mop) Plumbing Estimate $ (Commercial Only) Signature of Licensed Contractor The City of Rexburg's Water Meter Size: Business Name: License number e schedule is the same as Date the State ofldaho .. Please complete the el>~e Application! If the question d~not apply fill in NA for non applicable NAME PROPERTY ADDRESS Permit# SUBDIVISION Requi~~ed!!! Mechanical Contractor's Name: Address Contact Phone: ( ) Email Fax Zip Mechanical Estimate $~_ (CommerciaUMulti Family Only) FIXTURES & APPLL9NCES C NT (Single Family Dwelling Only) Air Conditioner Bath Fan Vents Range Hood Vents Boiler Cook Stove Vents Decorative Gas Fireplaces Dryer Vents Evaporative Cooler Exhaust or vent ducts Fuel (gas) piping fixtures or appliance outlets `$ Furnace Furnace/Air Conditioner Combo Heat Pump Incinerator Pool Heater Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Signature of Licensed Contractor Required! The Space Heater Unit Heater Date 's permit fee schedule is the same as required by the State of Idaho License number Mechanical Sizing Calculations must be submitted with Plans & Application Point of Delivery must be shown on plans. MECHANICAL Business Name: _City State Business Phone: ( ) 5