HomeMy WebLinkAboutAPPLICATION - 05-00437 - 1077 N 8000 E - Gas LineNOV-03-3005 10*32AM FROM-FALL RIVER ELECTRIC 208-652-7825 T-439 P.004/007 F-093
C1"TY OF ,REXB URG ~ •
BUILDING PERMIT APPLICATION
19 E MAIN, RIwXBURG, ID. 83440
208-359-3020 X322
PARCEL NUMBER:
SUBDIVISION:
(Addressing is based on the information - r
CONTACT PHONE #
PROPERTY ADDRESS:--- ~ O rI, ~ ~ ~~ cep ~ ~ ~~ -
PHONE #: Nome 3 Work ( ) Ce]] ( ) .,..~
OWNER MAILING ADDRESS: ~ alp ~ 3 ~'s-l S CY fY: ~~i~.,~STATE: I~7zIP:~C
EMAIL ~ ~ FAX ~/~
~~
APPLICANT: (If other than owner)
(Applicant if other than owner, a statement authorising applic q act as agent for owner mue;t accompany
APPLICANT INFORMATION; ADDRESS CITY:
STATE; ZIP MA FAX
PHONE #: Home { ) 'W'ork ( ) Cel] ( )
CONTRACTOR:
MAILING ADDRESS: ~' b ~ 0 CITY~t~-~_STATE l l~ ZIp ~3
PHONE: Home# I~~ Work# '(~ 7t/~~11# ~~,,,
EMAIL FAX ~0~- (oS~. _~~
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 Uring copy of new legal description of property}
PROPOSED USE: _~~`
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage, Ggmmercial,
application.)
etc.)
APPLICAANT° S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalry oPperjury, I hereby cQnify that T
hour read this Application and state that dre infoml3tion herein is conccr and T Swear chat any information which may hercaftel' be givrn by me in hearings before the
Planning and Zoning Commission or the Ciry Council Por the Ciry of Rcxbtttg Shall be truthful and correct. T agree to wmply wish all City robntlations and Slate laws
relating to the subject tnaacr of [his application and hereby authorized repre~entativcs of thq Ciry to enter upon the above-mentioned proporry Por inspections purptksg5.
NOTE: The building official may rovokc a permit on approval issued under the provisions of the 20001nu~tlaiion~-1 Code incases oPany false statemon[ or
ntisrcpregenwllion offact inthc applica[ipn or on the plans on which tho Permit or approval was baed- Permit void if nor starlgd within 180 days. Fermit void if work
stops Por 180 days,
~L~J ~ 1,
Signature of Owtaer/Applicant DATE
Do you prefer to be contacted by fax, email or phone? Circle One
WARNING - BIFILDING P~:RMIT MUST BE POSTER ON CONSTRUCTION SITIj!
Plan foes are non-ref~indable and are paid in fhtt at the time of application beginning Jra-ru~2l/l/S
City of Roxburg's Aace]rtancc ortl.o p]an review fep doC5 not CmL~iti[ute p]an approval
Flea OS 00437
If the 1 X77 N ~O~U ~: - Magi Cu. Mechanical '
~ .. ~. vvaaa rt~avt4c UtIS lUi yUU~
UNIT# BI.OCK# LOT#
rust be accurate)
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NOU-03-2005 10'.33AM FROM-FALL RIVER ELECTRIC 208-652-7625 T-439 P.005/007 F-093
p~CaSB CO>rxl~)ICre 1k~lC Cll~l~'C ,A~)~IlC'dt>iAn ~ If tl~e question does not apt-Iy X11 in NA Par ~~on
Applicebfe
NAME 11(1. r~ln( ~JCctr'
PROPERTY AD RESS 14'1 ~ ~ ~()~ ~-~nr..ZV~..Q~.. Pennit#
SUBDT'VISYON
.L,~equr~ed ~!! M.~CHAIVICAL
_ ~~
Mechanical Contraetor.'s Nance: ~ ~~~2~ji ~~nJ~i~ Business Name:
Address~~~ ~~D ,.,._ Ciry ~b~'~-C~(~.,.~State l Zip ~' 3~C)
Contact Phone: ~ ~ ~~J`~-- ~ L Business Phone: ( }
Email __ ~ ~' "'~--` ,,..,.. -Fax -
1Vlechanical Estimate $ (CommerciallMulti family Only)
FIXTURES 8c APPLIANCES CDUNT (Single Family Dwelling Only)
__ Air Conditioner ~ Space Heater
Batik flan Vents
Range Flood Vents
Boiler
Cook Stove Vents
Decorative Gas Fireplaces
~, Dryer Vents
Evaporative Cooler
Exhaust ox vent ducts
Unit Floater
~~~ ~ d1~
1~uel (gas) piping .fixtures or appliance outlets
rurnace
Furnace/Air Conditioner Combo
Float Pump
Incinerator
,,,_,~ )'ool Heater
Heat (Circle all that apply) Cra Oil Coal Fireplace Electric
Mechanical Sizing Calculations must be submitted v+vith Plans & Application
Foint of Delivery must be shown on plans.
~~~~~ ~ ~ t ~ -~ ~ -~D ~~~ ~
~gn~ture o LiC sc~! nt ,c~~tor/ License number ~ Date
The City oJ~Rcxburg's pzrrnit.%p schedule is tine sani~ aJ required by the SrQte Ufldaho
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