HomeMy WebLinkAboutAPPLICATIONS, BP - 05-00462 - 778 Poplar Cir - New SFRZ
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CIT,"YOFREXBURG •
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PERMIT # .
BUILDING PERMIT APPLICATION Please complete the entire Application!
19 E MAIN, REXBURG, ID. 83440 If the question does not apply fill in NA for non applicable
208-359-3020 X322
PARCEL NUMBER. ~ ~~, _ _ _ ~~ ~ ~ - - __( We will provide this for you)
SUBDIVISION: ('~{ ,h/`GY~~ ~~ UNIT# BLOCK#~LOT#
(Addressing is based on the information -must be accurate)
OWNER NAME: CONTACT PHONE #
PROPERTY ADDRESS: 7]g ~~/~ C!^. ~~i~~rJ/~a L~'J,
PHONE #: Home ~) ~ 6- ~/~Qz Work ( ) Cell~~ ~~-- ~~~7
OWNER MAILING ADDRESS:~'~ ~t1Q ~~a~ CITY: STATE~ZIP:~~~
EMAIL ~ FAX ,~
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
,~- r ; ; ~ 7 i ----. l
APPLICANT INFORMATION: ADDRESS tr~1 , ; l ~,; ~ ;, ;i.
c
STATE; ZIP EMAIL ~ 1*~AX ,
N ~~ ~ :, ~ '
PHONE #: Home ( ) Work ( ) Cell (' `') ~--~
---
CONTRACTOR:
MAILING ADDRESS:~~~~,y~d~`4j~ CITY STATF~i~. ZIP~~~
PHONE: Home# ,S~ Work# Cell# ~~9 -y~g'7
EMAIL ~----- FAX
How many buildings are located on this property? ~ ~
Did you recently purchase this property? No Yes f yes give owner's name) ~ti fi~,~;,~" ~ ~~ ~~S/a fa°
Is this a lot split` NQ YES (Please _bring
PROPOSED USE: iU
(i.e., Single Family Residence, M i Family, Apartm~
of new legal description of property)
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 o ~a~~al was based. Pern}it void if~ot started within 180 days. Permit void if work stops for 180 days.
~~~~~
DATE
Do you prefef 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**
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~..._... '~' ah _ r .._..~.. ~ ~-,' - - ;:ice ...,._,.....~
ti AMERICA'S FAMILY COMMUNft•Y 19 E. Main (PO Box 280) ~ Phone: 208-359-3020 x326
Rexburg, Idaho 83440 Fax: 208-359-3024
www.rexburg.orq comdevC~rexburg.org
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
N me Address
.~~J~
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 recor owner of the p erty described on the attached, and I grant y
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 ~ y ~ylri -e ~' , 20 Dew
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Please complete the e>~re Application!
NAME I t e que~ on does not apply fill in NA for non applicable
r z~e
PROPERTY ADD SS r ,~jv~ ~~, Permit#
SUBDIVISIO ~~
Dwelling Units:
Parcel Acres:
SETBACKS
FRONT 3 ?j~ ~ SIDE ~ ~~ SIDE ~ ~ ~~ BACK ~ ~/
Remodeling Your Building/Home (need Estimate) $
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area ~,3 ~ ~
Second floor/loft area ---
Third floor/loft area --~
Shed or Barn
Unfinished Basement area l 3c~0
Finished basement area
Garage area
Carport/Deck (30" above
Water Meter Quantity:
************** Water Meter Size:
Required!!!
PLUMBING
Plumbing Contractor's Name: y' ~ ~ q h [- ,y~fi Business Name: ~/ v.~ ~ ~,~c~a Q /~'g/t~ ~~
Address ~ ~)( ~~ ~ ~~~ y~ City State Zip~~ ~. ^ ~
Contact Phone: ~o~) ~~'$"- Gf / ~ ~ Business Phone: (~p~j ~o ~/ - ~/~ '7
Email
FIXTURE COUNT (including roughed fixtures)
~ Clothes Washing Machine
/ Dishwasher
~ Floor Drain
~_ Garbage Disposal
Hot Tub/Spa
~_ Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $
(Commercial Only)
Sprinklers
°~ Tub/Showers
Toilet/LTrinal
_~ Water Heater
Water Softener
G L
of Licensed `'ontractor icense number
The City of Rexburg's permit fee schedule is the same as
~~
Date
' by the State of Idaho
Fax ~~~-~ ~~~
Please complete the entir~Appllcatlon! If the question does not apply fill in NA for non
applicable
NAME
PROPERTY AD SS r ~ ~, Permit#
SUBDIVISION #~
Required!!!
MECHANICAL
Mechanical Contractor's Name: ` Business Name: ~1~,~~~-/~
Address ~~~ ,~ ~~~/ ~/;~ City ,~~,,-~ State ~ Zip~l~
Contact Phone: ~' _ l ~ Business Phone: -----
Email fLj~~l~~ja-~ /l s J~~ ~'J ~ ~ Fax ,-~D~ ~r~~ ~~
Mechanical Estimate $ (CommerciaUMulti 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
,k Bath Fan Vents
other similar vents & ducts:
~• Fuel Gas Pipe Outlets including stubbed in or future outlets
i~ 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.
~~
Signature of Licensed Contractor
The City of Rexburg's permit
c ~;o~~
License number
schedule is the same as
-ar ~
Date
the State of Idaho
,~
i
...........................................................................................
SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete:
Masonry:_~~~).C~ c f o •t~ e / ~~ aA~ l^>r
Roofing:
Insulation:
Drywall:
Painting:
Floor
Coverings:
Plumbing: i'(~t ~ (] ~~~
Heating: j'/G UJ~. ~~( ~~ G ~~"J G
Electrical: G, ~ ~~ /'1 L
Roof Trusses: ~ ~DG
Floor/Ceiling Joists:
Siding/Exterior Trim:
Other:
Special Construction
(Manufacturer or Supplier)
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