HomeMy WebLinkAboutAPPLICATION - 05-00387 - 555 W Main St - Fireplacey i •
CITY OFREXBURG ~~ 00387
BUILDING PERMIT APPLICATION 555 W M a i n -Fire lace
19 E MAIN, REXBURG, ID. 83440 h
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)
_....~.
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CONTACT PHONE #
PROPERTY ADDRESS: S ',.~~ ~ , ~,,.~„
PHONE #: Home ( ) ,~~ ~~-.~~? ~ Work ~( ) Cell ( )
OWNER MAILING ADDRESS: -~~~ (,c~r ~1d~,... CITY: ~? ~~~ct~TATE:,~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'
ZIP EMAIL
CITY:
FAX
PHONE #: Home ( ) Work ( ) Cell ( )
--
CONTRACTOR:
FAX
MAILING ADDRESS: CITY
PHONE: Home# ~-~ ~ Work# s~.~ Cell#_
EMAIL
STATE ZIP
How many buildings are located on this property? eYYr~2,
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
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 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 offact 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.
Signature of Owner/Applicant DATE
Dc~ yc?~l plef~;l~ to be contacted I~}j f4lx, elnail or pl7otlc`? {~'ircle 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 Januarv 1. 2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval
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,se complete the entire Application!
- ' ,icable
-MME
~ROPERTY ADDRESS
SUBDIVISION
If the question does not apply fill in NA for non
Permit#
Required!!! MECHANICAL
Mechanical Contractor's Name: J':~ ~,~,~a' ~~~._-f-.r,,,~~ Business Name: ~~y ~~~~~
Address~_~ ~, ~y ~"fu City' ~ ~~~I~State ~"~~~ Zip~~ f
Contact Phone: ( ) Business Phone: (,~p~ iL.- ~ ~ ~`
Email
Fax
Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLL4NCES COUNT (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
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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