HomeMy WebLinkAboutAPPLICATION - 05-00440 - 3972 N 6000 W - Mechanical%.~ruc,.~~.~ Owe.a 5 °71(0- 13Z~
~-~'~ OF REXB URG ,,. _u
~.~_:~,.~~ w.~~t,.~~..~:~.. .:.y~~....~.~~.;. ~ ~ . ~~~... u..., ~ 00440
BUILDING PERMIT APPLICATION Please ~
19 E MAIN, REXBURG, ID. 83440 If the qu 3972 N 6000 W-Mad. Co. 1VIech
208-359-3020 X322
PARCEL NUMBER:
SUBDIVISION:
We will provide this for you)
UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
OWNER NAME: ,; ~,~-~ ~y,., l CONTACT PHONE #
PROPERTY ADDRESS: ~9`I2 ~. ~ D~0 GJ• ~->l~vr~ , .~~
PHONE #: Home (ZQ$")~3,5-~ ~°3$~,~ Work
OWNER MAILING ADDRESS:
EMAIL
FAX
Cell ( )
CITY: p yr STATE~~GIP: g3~~C~
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:
S' ATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR: .1Jo u b I ~ /~ C,~~ S
MAILING ADDRESS://3 R f~,"vc_~ )y~•CITY STATE,~2ZIP 3~1~v
PHONE: Home# 3s~ -- ~D~~ Work#
EMAIL FAX 356 `' ~0 3$
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 Pl g and Zoning Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply
with all City regulatio an State laws relating to the subject matter of this application and hereby authorized representatives of the City to enter
upon the above-m ion property for ' spections purposes. NOTE: The building official may revoke a permit on approval issued under the
provisions of 00 ternational de in cases of any false statement or misrepresentation of fact in the application or on the plans on which the
permit or ap ov as b~ed~ rt void if not started within 180 days. Permit void if work stops for 180 days.
~i~~ i~
Sin o wne~ Applicant DATE
Do you efer 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 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**
Cell#
r
.ease complete the entl Applca~ion~!~ if the question does'~ot apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: ~r~ub tc ~ ~~' S Business Name: " /~ ,~ 'S
,~~ O
Address //;35~ ~}~ ~'~c/s~ ~y ~dc1 ~ City ~eX bvr~ State~_ ~ Zip
Contact Phone: (Zo8) 3 %3 " ~~ f D Business Phone: (2~ S )~~'~ - X08
Email
Fax ~~ ~- ~d.:3 ~'
Mechanical Estimate $ (Commercial/Multi 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
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Similar fixtures or Appliances ~~
' Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI ~`-
Heat (Circle all that apply as Oil Coal Fireplace Electric
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