HomeMy WebLinkAboutAPPLICATIONS - 05-00376 - 253 S 2nd E - MechanicalCITY OF REXBURG
___. .:.~
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X322
PERMIT #
Please complete the entire Application!
If the questi~
PARCEL NUMBER: Z~QS,~1 ~ C~ ~i~3 ~ f (We
SUBDIVISION: UNIT,
(Addressing is based on the information -must be accurate)
05 00376
Mech. - 253 S 2nd E
---
OWNER NAME: CONTACT PHONE #
PROPERTY ADDRESS: t~~ ~Sc~w~ "7nc~ ~-S~
PHONE #: Home
OWNER MAILING ADDRESS:
EMAIL
FAX
CITY:
STATE: ZIP:
APPLICANT (If other than owner) -;l ~ ~~ ~ -XSIf -
(Applicant if other than owner, a statement authorizing applicant to act as agent f owner must accomp ny this application.)
APPLICANT INFORMATION: ADDRESS l~~p` ~'~` ~~r~ 5e~"~y~~~ CITY: ~.~L
STATE; ~"' ZIP ~ 3 ~ EMAIL
PHONE #: Home ( ) _~ ~~, -~ ~/~~ Work
Cell
Cell
FAX
CONTRACTOR:
MAILING ADDRESS: /~~_ , ,~~,~ ti~~~'lr -~"~~' ~'~ CITY >~~ STATE.t",~ ZIP ~.j'f~10
PHONE: Home# .~.SZ= -Y/1 i Work#
EMAIL
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:
(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 applic tion or on the plans on which the
perm/it or approval was base1d. Permit/void if not starte/d~ w-ithi~n,180 days. Permit void if k stops for 180 day .
/n :Y 7.-~ ~/ia .,..,1/I;rr~ ~", /'~WhL~ -/~~ ~ .~~~it~ ~ ~LLI
Signature of Owner/Applicant ' ~ llA1>:
Do you prefer to be contacted y fax, email or p one? 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**
FAX
Work
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
City
Being first duly sworn upon oath, depose and say:
A.
Address
State
(If Applicant is also Owner of Record, skip to B)
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 of the application.
Dated this day of , 20
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
T.
..~ ~~ . _~ . 1>< at><on. ~ J v
Plea~c mom fete the ~><re A c
P pP
If the question does not apply fill in NA for non applicable
NAME _
PROPERTY ADDRESS
SUBDIVISION
Dwelling Units:
SETBACKS
FRONT
SIDE
SIDE
BACK
Remodeling Your Building/Home (need Estimate) $
Permit#
._..* /
~.1,~ ~~;
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
)Area
Water Meter Quantity:
************** Water Meter Size:
Required!!!
PLUMBING
Plumbing Contractor's Name: ~-~~- ,~ u Business Name: ~ „~
Addres City ~~---State'I ~E~ Zlp.
Contact P one: l /~ 1 ~ Business Phone: ( )
Email
FIXTURE COUNT (including roughed fixtures)
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, mop)
Fax
Sprinklers
Tub/Showers
Toilet/Urinal
Water Heater
Water Softener
Plumbing Estimate $ (Commercial Only)
11 ~ ~~ ~~~
ignature of Licensed Contractor License number Date
The Ci of Rexburg's permit fee schedule is the same as required by the State of Idaho
Parcel Acres:
Please COIIlpICte tale eilt~ AIJpI1Cat1011 ~ If the question doe• t apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: ~ ~_~ Business Name: ~,.~,~~A ~,
Address ~ ;~ ~,~ City `~ ~~ ~~ Stat ' Zip~j
Contact Phone: (~ ~ ,-----~ ;, f ~ Business Phone: ( )
Email
Fax
Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLL4NCES 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
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
R
~Si ature of Licensed Co tractor
The City of Rexburg's
I~~~ ~~ ~~
License number Date
schedule is the same as required by the State of Idaho