HomeMy WebLinkAboutAPPLICATION - 05-00471 - 1807 W 5350 S - New SFR MechanicalCITY OF REXB URG , 00471
BUILDING PERMIT APPLICATION P1easE ~
19 E MAIN, REXBURG, ID. 83440 If the qu 1807 W 53 50 S-Mad. Co. Mech.
208-359-3020 X322
PARCEL NUMBER: ~~~! VS ~ ~ ~~~j" o (We will provide this for you)
SUBDIVISION:~~~~~ p ~ UNIT# BLOCK#~LOT#~
(Addressing is based on the information -must be accurate)
OWNER NAME: Uuc.~ CONTACT PHONE #
PROPERTY ADDRESS: ~ g~®~ ~° ~J vz`~ S.
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: CITY: STATE: ZIP:
EMAIL FAX
APPLICANT (If other than owner) ~. ~ ~`,~ c
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this applica~~ti
APPLICANT INFORMATION: ADDRESS~~~,~,~~~~ C ~~ ~ ~ l~~
STATE; ZIP EMAIL
PHONE #: Home
Work
CONTRACTOR: ~~- -~
MAILING ADDRESS: ~ -~~~Q ~~ CIT'
PHONE: Home# ' _ ~' Work# S - Cell#1
EMAILSf~a;.){_~ ~~ir~i/.~ FAX ~~ ~ --~~l~~j"
.~ n ~_
F
Cell ( _
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STATE~L ZIP~~~~L
now many nullamgs are Iocatea on this property'! f
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: ~/'~~~~ Cl/~i~%/ ~, ~ ~~
(i.e., Single Family Residence, Multi amity, Apartments, emodel, 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
perr}~t or approval was based. Permit void ifpot started within 180 days. Permit void if work stops for 180 days.
~/ ~~ / C~
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**
please complete the ent~ Application! If the question doe~t apply fill in NA for non
applicable
PROPERTY ADDRE S P $ b ~ ~" ~ .~ , Permit#
SUBDIVISION ~.
Required!!!
MECHANICAL
Mechanical Contractor's Name: ~ Business Name:
Address °~ ~s9 ~ ~(Uc7 ~ City ` State ~ Zip g3 y~%S~
Contact Phone: (%~~) 31.3 ' ~ ~% 7 Business Phone: 08) ~a ~/ ~ /~6/t
Email
Fax
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES COUNT (Single Family Dwelling Only)
Air Conditioner
Bath Fan Vents
Range Hood Vents
Boiler
Cook Stove Vents
Decorative Gas Fireplaces
Dryer Vents
Evaporative Cooler
_~ Exhaust or vent ducts
~ Fuel (gas) piping fixtures or appliance outlets
f Furnace
Furnace/Air Conditioner Combo
Heat Pump
Incinerator
Pool Heater
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
Space Heater
Unit Heater
Mechanical Sizing Calculations must be submitted with Plans & Application
~~ ,~ Point of Delivery must be shown on plans.
Signature of Licens 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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