HomeMy WebLinkAboutAPPLICATION - 05-00406 - 1721 W 4200 N - Gas Line~Y OF REXB URG PERMIT # '
BUILDING PERMIT APPLICATION Please complete th entire Application!
19 E MAIN, REXBURG, ID. 83440 If the quP~+'^" a^°° °^+ °-~--'-- ~" ~- AT A r__. __ . •• • ,e
208-359-3020 X322 c
PARCEL NUMBER: ( ~ 5 o O~ O v
Gas Line Inspection -Mad. Co.
SUBDIVISION: U
(Addressing is based on the information - must be accurate)
OWNER NAME:
CONTACT PHONE # ~~Sl
PROPERTY ADDRESS: [ -7~_~, ~-Z.~c~ $~,
PHONE #: Home ( ) Work ( ) Cell ( ) ..~f ' /f 3
OWNER MAILING ADDRESS:
EMAIL °°~--
CITY:~~~~STATE:~D ZIP: ~~®
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
PHONE #: Home
EMAIL
Work
Cell
CONTRACTOR:
FAX ~-
MAILING ADDRESS: ~~~ ~~~ 1 CITY v ~ STATERS ZIPS
PHONE: Home#
Work# ~(d--~G1~~ Cell#
EMAIL -£~--, FAX -~-'
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 spli . NO S (Please bring copy of new legal description of property
~!`~' C~~ p~BURQ
PROPOSFI~ T TSE:
'.., Single Famil esidence, 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.
/ /_
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 Regburg'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**
CITY:
FAX
• ~ .~~sC COIl1p~C~e the eII~l AppIlCa~lO ~ ~ If the question doe~t apply fill in NA for non ~~~~~~ ,
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Required!!!
Mechanical Contractor's Name:
Address
Contact Phone: ( )
Email
MECHANICAL
Business Name:
_City
Business Phone:
Fax
State
Zip.
Mechanical Estimate ~
(Commercial/Multi Family Only)
FIXTURES & APPLL9NCES 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 ~ Y~0 ~"
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:
~~-sid ~ c~,~ 1 ~/
ical Suing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Permit#
l - d~ -o~
Contractor Licens number Date