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HomeMy WebLinkAboutAPPLICATION - 05-00407 - 201 S Mill Hollow Rd - Gas LineCITY OF REXB URG ~ PERMIT #~ BUILDING PERMIT APPLICATION Please complete the entire Application! 19 E MAIN, REXBURG, ID. 83440 If the question -' ~ °° - - ` - ~-_ _ _ _ 208-359-3020 X322 05 00407 PARCEL NUMBER:p2~5D~~,d (We ~ Gas Line Inspection/Pressure Test- Mad. Co. SUBDIVISION: UNIT#_ (Addressing is based on the information -must be accurate) OWNER NAME: CONTACT PHONE # PROPERTY ADDRE S: ~ p I 1 ~ `~ J` ~ I~.JI..~ PHONE #: Home u c ~ ~ ~~2 Work ~o~ ~- ~ ~lo© Cell OWNER MAILING ADDRESS: ~~/Y1L~ CITY: -~N ' _ ~~~ ~~ - •-. ~f~~ z~~~ STATE EMAIL I-1 ~ ~ t F~ I ~~~~~ ZIP: I~N~ s ~t1~ 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 PHONE #: Home ( ) Work Cell FAX CONTRACTOR: N'Fl~ 1~G ~ ~` 2 (~~ /~ MAILING ADDRESS: CITY STATE ZIP PHONE: Home# Work# 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 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 application or on the plans on which the permit or approval was based. Permit void if t st ed 180 days. Permit void if work stops for 180 days. ~- Signature of er/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 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** ease compI~e~e ~~ie`'ei~pp~'Tica~ion If the goes applicable NAME L°/v ~_ L~ ~/ C:. f PROPERTY ADDRESS ~ ©( ~'1 C ~ ~l B ~~ SUBDIVISION r non Permit# Required!!! MECHANICAL Mechanical Contractor's Name: x4X%~~ 1 ~ N /~iusiness Name: '~ ~~,y - Address ~~ ~* _ ~ ~ ~ " ' ~ City ~ -~ State ~ I Zip l~ ,~~-~~ Contact Phone: (~' ~) s~~ ~~©~ (.~ ~ Business Phone: ~~ ~~~ ~/ ~~ Email Fax 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 Similar fixtures or Appliances Dryer Vents Range Hood Vents Cook Stove Vents Bath Fan Vents other similar vents & ducts: ~ UN~ ~~ ~ ~~ ~ ~ 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 ,.j ~ A ~r~ Mechanical Sizing Calculations must be submitted with Plans & Application Point of Delivery must be shown on plans. 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 pease complete the en I ~ppllCatlOn~!' If the question does not apply fill in NA for non applicable ~ ~ _ _ NAME ~L I~ -=-~ _ ~C=:rL" .~l ~ ~~~ /~ PROPERTY ADDRESS :~' ~ ( ~'Y1(/ j ~Tc%~j~3 ~-~~ Permit# r- ~J SUBDIVISION ~ ~d ` L~ 1 ~~ Required!!! MECHANICAL Mechanical Contractor's Name: ~ - `~t~X:' ~~- '~ `~ h ° ~-~- ~ usiness Name: ~''t ----'-- Address Contact Phone: Email (~~~~'Z~(_~ ; ; ~ ~~ ~ City ~ `~-~, State I Zip ~~~~ ~~~ ~ (.~ ~ Business Phone: ~~~ J~~ ~/ Fax Mechanical Estimate $ (CommerciaUMulti Family Only) FIXTURES & APPLIANCES 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 Dryer Vents Range Hood Vents Cook Stove Vents T Bath Fan Vents ~ other similar vents & ducts: 'I~i ~~p~, ~ i. -~ ~ y ~ ~ ~---__ 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. g l„m _... Signature of Licensed Contractor The City of Rexburg's License number schedule is the same as Date the State of Idaho