HomeMy WebLinkAboutAPPLICATIONS - 05-00344 - 175 N 1st E - RemodelCITY 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:
PROPERTY ADDRESS: r~
FAX
PHONE #: Home (Z.o~) `~~S(o° 5 ~ ~(r, Work
OWNER MAILING ADDRESS: .Save
EMAIL
Cell ( )
CITY: Q.~zx~,,v~~ STATE~~ ZIP: $3yyC7
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL.
PHONE #: Home ( )
~r~- ~~ , t! LL
CITY:
FAX
Cell ( )
CONTRACTOR:
MAILING ADDRESS: ~~~ ~L
PHONE: Home# ~aS(~._ ~')~$~ Work#
EMAIL
FAX
.e CONTACT PHONE #
Work ( )
.~~~ CITY ~.~~~ STATE `T.p ZIP 3y`1 ~
Cell# ~ I G~ - i 3~ lQ
How many buildings are located on this property?
Did you recently purchase this property?~ Yes (If yes give owner's name)
Is this a lot split? NO YES (Please brting connpy of new legal description of property)
PRnPOSF,D USF,: ~Rt itia`~ ~~ + \ v Y-ej- r~ ev C,~
(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 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.
ign~ Owner/A licant 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**
~~~
a~p+
GTY O~
REx~uR~
AMERICAS FAMILY CC?MMUNI"fY
i
_ __ ___
19 E. Main (PO Box 280) Phone: 208-359-3020 x326
Rexburg, Idaho 83440 Fax: 208-359-3024
www.rexburg.org comdevCc'~rexburg.org
Affidavit of Legal Interest
State of Idaho
Coui /nty of Madison `` ~, `
Name Address
~~ ,
clty
Being first duly sworn upon oath, depose and say:
~ ~<~
State
(If Applicant is also Owner of Record, skip to B)
A. That I am the record owner of the property described on the attached, and I grant my
permission to:
Name
Address
to submit the accompanying application pertaining to that property.
B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any
claim or liability resulting from any dispute as to the statements contained herein or as to
the ownership of the property which is the subject Hof the application.
Dated this j ~~ day of `aeal~... ~-+-.r , 20 f~S
Signature ~ ~
Subscribed and sworn to before me the day and year first above written.
\\\~a~~ u w + u f ~//~~~~~
~`~`\\Q~~N P?~~`~~~~i'/ Notary Pu lic of Idaho
\ ~~ . ~O Tqq`~. ~ j 1Q
y ~~ ~ rn _ Residing at:
s s ~
A
u' ''•. ve l1G ~ My commission expires: `?"~~I C~~U
.....N ~
~i/~~~~i~rF •O F 10 ~O~`\`~
~lllll f 111111~~~~
Please complete the e~ire Application!
If the uestion does not apply fill in NA for non applicable
NAME 2 i~ W , ~-0~1 ~ ,,,.,,
PROPERTY ADDRESS 5 ~ ~' ..~- Permit#
SUBDIVISION ~' , ~y ~ ~.u ~ti; ~,
Dwelling Units: Parcel Acres:
SETBACKS
FRONT ~ ~ SIDE hl ~ SIDE
~t~
Remodeling Your Building/Home (need Estimate) $ '~b(~®`5°
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
Carport/Deck (30" above g
Water Meter Count:
Water Meter Size:
Required!!!
PLUMBING
Plumbing Contractor's Name:
Address
Contact Phone: ( )
Email
FIXTURE COUNT (including roughed fixtures)
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $
(Commercial Only)
Business Name:
BACK
)Area
~~
Sprinklers
Tub/Showers
Toilet/Urinal
Water Heater
Water Softener
City
Business Phone:
Fax
State Zip
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
Please complete the enti~Application! If the question does~t apply fill in NA for non
applicable
NAME e ~ ~ ~ , ~~~ ~ v~
PROPERTY ADDRESS ~~S ~„-v~~ ~ ~.,-~- Permit#
SUBDIVISION ly R
Required!!!
Mechanical Contractor's Name:
Address
Contact Phone: ( )
Email
Business Name:
_City State
Business Phone: ( )
Fax
~~
Zip
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
Furnace/Air Conditioner Combo Dryer Vents
Heat Pump Range Hood Vents
Air Conditioner Cook Stove Vents
Evaporative Cooler Bath Fan Vents
Unit Heater other similar vents & ducts:
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
Heat (Circle all that apply) 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
MECHANICAL
~~
SUBCONTRACTOR LIST
Excavation & Earthwork:
/J / /~
Concrete: ~~' ~ C off' ~ C ~ ~ C ~J ~ f~.._-~) ~e.~..~ ~ ~T~ 5~ ~ ~ ~~~ i o~.~ \I
Masonry:
Roofing:
Insulation:
Drywall:
Painting:
Floor
Coverings:
Plumbing:
Heating:
Electrical:
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceiling Joists:
Siding/Exterior Trim:
Other: