HomeMy WebLinkAboutAPPLICATION - 05-00408 - 1952 W 7600 S - Mechanical.-.c~
T.EXB URG j..
~~ BUILDING PERMIT APPLICAI~ON
' 19 E MAIN, REXBURG, ID. 83440
208-359-3020 X322
PARCEL NUMBER:
05 oo4os
SUBDIVISION: - Furnace Installation -Mad. Co.
(Addressing is based on the information -must be accurate.
CONTACT PHONE #
PROPERTY ADDRESS: ~Q~a~ Il~lO~ 7'v~G~ .S~ ,
PHONE #: Home ( ) Work
OWNER MAILING ADDRESS:
EMAIL
FAX
Cell ( )
CITY: ~ STATE:~ZIP:~~O~
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
PERMIT #
Please complete the entire Application!
If the q"QQ*'^*' r~naa not annly fill in NA fnr nnn annliCable
CITY:
STATE; ZIP EMAIL
PHONE #: Home ( ) Work
FAX
Cell
CONTRACTOR: ~
MAILING ADDRESS: CITY
PHONE: Home# 3-•~v -yl/'~ .Work .35~, ~~~ Cell#
EMAIL FAX
How many buildings are located on this property? ~ ~ ~
Did you recently purchase this property? ~o 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 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 SITE1
Plan fees are non-refundable and are paid in full at the time of application beginning January 1, 2005.
City of Rezburg'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**
STATE~~ZIP
..~..~,~_.~....,.,._.,.,~.V...~,. ,~.~.,.~,..,.V.w.....,. ~..._.. „~..u...n.,..~,.~..~...~..,...__ ...~..~,.~.
~~ ~ CITY
~ ~ ~,
a R~:xBUR~ .
qe ~ AMERICA'S FAMILY COMMUNITY 19 E. Main (PO Box 280) Phone: 208-359-3020 x326
~~ Rexburg, Idaho 83440 Fax: 208-359-3024
i
vrww.rexburg.org comdevCc~rexburg.org
I
Affidavit of Legal Interest
I,
State of Idaho
County of Madison
Name
Address
City State
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
A. 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:
li ..' -
~'lease complete~the ~ir~~A~pplicationA~~ ~" ~ ~~
If the question does not apply lill ir- fir'.<0 fu-• nf~n ~~i~plir.~a~~le
NAME
PROPERTY ADDRESS
SUBDIVISION
Dwelling Units:
SETBACKS
1~'RONT
SIDE
Remodeling Your Building/Home (need Estimate) $
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
SIDE
Unfinished Basement area
Finished basement area_
Garage area
Carport/Deck (30" above g
Water Meter Quantity:
k ~::~_ ., ~ :,::,::,::,: ~ _ =., Water Meter Size:
~~~~~~-Idi~ecl! r r
PLUMBING
Plumbing Contractor's Name:
Address
Contact Phone: ( )
Email
City
Business Phone:
Fax
Permit#
e
State
Zip
FIXTURE COUNT (including roughed fixtures)
Clothes Washing Machine
Dishwasher
Floor Drain
I, Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $
(Commercial Only)
Sprinklers
Tub/Showers
Toilet/Llrinal
Water Heater
Water Softener
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
BACK
Business Name:
Parcel Acres:
~.. ~ ~....,,~~a...~...~-.~, _~.a...a,...._~....v... -----,...~ . ,
Please COri1j)Ie~C ~he~en pp ICa IOIl. If the question does not apply lill.in NA for non
applicable
Permit#
NAME
PROPERTY ADDRESS
SUBDIVISION
Required!!!
Mechanical Contractor's Name:
Address
Contact Phone: ( )
Email
_City
Business Phone:
Fax
Mechanical Estimate $
MECHANICAL
Business Name:
(CommerciaVMulti Family Only)
State Zip
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
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
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.
gnature of L censed Contractor License n tuber
Date
~ The City of Rexburg's permit fee schedule is the same as required by the State of Idaho