HomeMy WebLinkAboutAPPLICATION - 05-00444 - 784 Barney Dairy Rd - New SFR Mechanical` CI~'Y OF REXB URG , P •
BUILDING PERMIT APPLICATION Please co: ~~ 00~~-~
19 E MAIN, REXBURG, ID. 83440 If the question ~~~ ~3tlrneV Daily Rd-Mad. Co. Mech.
208-359-3020 X322 `~ A ' -~ -'
PARCEL NUMBER: ~~ y~-~V ~ b~~~~(~~We w~~~ Y~.,v~u~ ~rrr~ ~~~ y~u~
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
OWNER NAME: G_~„,~; ~ plu s k , ~ ~ r< r~ CONT~-A,CT PHONE #
PROPERTY ADDRESS: w] ~?~ pct -fZ~n ~ .a ~~ i r~,~ l~
PHONE #: Home ( )
OWNER MAILING ADDRESS:
EMAIL
Work ( )
CITY:
FAX
Cell ( )
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;
PHONE #: Home ( )
CI'I
FA
Cell ( )
STATE: ZIP:
--~
I
a
1a~V 1 4 2~~
CONTRACTOR: _~
MAILING ADDRESS:
PHONE: Home#
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: ~j'~-h <il~ F~tv-r~e.1
(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 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**
ZIP EMAIL
Work ( )
CITY
STATE ZIP
~~'hase complete the enti~Application!
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
If the question doe apply fill in NA for non
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: S}~„~ }~~, ~ ~ ~~1 Business Name: ~ ~ ,, ~C ' ~ ~ ' ~/-~<;~
Address CityW~= .t ~„4~~ State ~~ _ Zip
Contact Phone: (Zi;~)_;~ ~ ~~- - ~ ~ ~,~ Business Phone: (~~) 35 ~, _ L! I I ~
Email
Fax
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
~ Air Conditioner
3 Bath Fan Vents
Range Hood Vents
Boiler
Cook Stove Vents
Decorative Gas Fireplaces
Z Dryer Vents
Evaporative Cooler
Exhaust or vent ducts
Fuel (gas) piping fixtures or appliance outlets
Furnace
~ Furnace/Air Conditioner Combo
Heat Pump
Incinerator
Pool Heater
Space Heater
Unit Heater
:Heat (Circle all that apply) Ga Oil Coal Fireplace Electric
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
I ~~'~ ~ t~~~ ~
ignature of License Contractor License number Date
Required!
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
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