HomeMy WebLinkAboutAPPLICATION - 05-00388 - 795 W Poleline Rd - FireplaceCITY OF REXB URG ~ PERMIT # ~
BUILDING PERMIT APPLICATION Pl ~ `ion ~
19 E MAIN, REXBURG, ID. 83440 If ~ 0 5 0 0 3 8 8 licable
208-359-3020 X322
PARCEL NUMBER: 795 Poleline Rd -Mad. Mech
SUBDIVISION: UN11# BLOCK# LOT#
(Addressing is based on the info ation -must be accur te)
~ - ~ -° ~~"
OWNER: CONTACT P ONE # ,~$"~ °'~Z~~ j~~
PROPERTY ADDRESS: ~~ ~/ ~~~~,~ ,~,o~ ,~~~t ~.~rc~
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: CITY: STATE: 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 CITY:
STATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR !~ ~ S ~ ~lsr'/~r! S.rz.S Ll1' ~ ~i/ 1//.~ /~~~ ~
MAILING ADDRESS: ,~~/y ~ 7~ ~/ CITY ~~ STATE~~ ZIP
PHONE: Home#~?,~;3,SO~ Work#~. Cell#z~i,7., y/7o
EMAIL FAX
How many buildings are located on this property?
Did you recently purchase this property~~es (If yes give owner's name)
r.,.,._
Is this a lot split~~ NO.%l YES (Ple`ase bring copy of n>ew legal description of property)
PROPOSED USE.: ~`n~/~ ~~.~~/~
(i.e., Single Family Residence, Multifamily, Apartments, Remoetel, 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 prope for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the
provisions of the 2000 Inte ati al 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 b ed ermit void if s ed within 180 days. Permit void if work stops for 180 days.
Signature of Owne /App scant " ll~/~/~
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**
Tease complete the entire Application!
applicable
NAME ~- l/l~ ~~
PROPERTY DDRESS
SUBDIVISION
If the question doe~t apply fill in NA for non
i~~ - Permit#
Required!!! ~C NICAL
~~`-~ ~~
~ J~~
Mechanical Contractor's Name: 4 ~"/SOS Business Name;/ / ~ ~~
.-~
Address~~~l~f ~` ~_~~ il/ City State /~ Zip~~f~
Contact Phone: ~:~) ~ ~5~- Business Phone: (~) ~~j/7- y/tea
Email
Fax
Mechanical Estimate (Commercial/Multi 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
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
APPRO ED ~'t8J'lJS
iN~dY! _ l/ l~(/1r~5
BUILDING iNSr'~`' ~ ~~
Similar fixtures or Appliances
Fuel Gas Pipe Outlets including stubbed in or future outlets ~`~~1`nd,`~
w~ C ~;t,QAac~,
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.
Sig ature of tense ontractor 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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