HomeMy WebLinkAboutAPPLICATION - 05-00472 - 1045 N 5th W - MechanicalCITY Off' REXBURG
BUILDING PERMIT APPLICATION
19 E MAIN, REXBLRG, ID. 83440
208-359-3020 X322
PARCEL NUMBER:
( We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
CONTACT PHONE ~ ~ S~ -,~55 3
PROPERTY ADDRESS: / U y S IU. ~ ~L•fl~ ~ -~~~
PHONE #: Home (~) v'S~ - ASS 3 Work ( ) Cell ( )
OVb'NER MAILING ADDRESS: Qi 9 S -~!• 5 % ~.J, CITY: ~x ~ ~~ STATE: L G~ZIP:g'3yy~
EMAIL FAX
APPLICANT (If other than owner) C'~5• d ~.~5; s ~, f=~ ~~ ~--r
(Applicant if otherihan owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS ~.SS.S. ,,ttp~/ou„/a ~~i'Dl CITY: ~l~ ~ r~'
STATE; T ~ ZIP ~y`/C%' EMAIL FAX 35~ - 3~ ~~
PHONE #: Home
Work (~ 35 S-~~~ b~ Cell
COtVTRACTOR: ~-"u a Jp ~•~. ~~„~~ (-. f..~l,-~.JS
MAILING ADDRESS: ,~ 5 ~ ~• '~o/%~s/ea.., ~gd/ CITY 1~~~~•~ STATE.~L`~ ZIP~3~/~/~
PHONE, Home# Work# 3S~ ~U~~Cell# "'"---.,~;.~~
EMAIL FAX 3 S G - 3 g 8'"~l' D ~ ~~ '`7 ~~
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How many buildings are located on this property? '- ' ~ 1'
k.-..
Did you recently purchase this property? No Yes (If yes give owner's name) 1~y'---_ ____
--- -
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 1 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 Cit}° regulations and State la~i~s 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 lntemational 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 base~rmit ve~~.f-nntjstarte~yhyithin 180 days. Permit void if work stops for ] 80 days.
i
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Signature of OwneriApplicant ~ DATE
Do you prefer to be contacted by fax, email or phone? Circle One
Vb'ARNING-BUILDING PERMIT MUST SE POSTED ON CONSTRUCTIOV SITE!
Plan fees are Wort-refundable and are paid in full at the time of application beginning Januan~ 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*'~
P~
05472
Plea
>«thE 1045 N 5th W-Mad. Co. Mech. °a e
Dec 01 05 10:53a Myron Creager 208-356-3988 p.2
~~ease complete tlae enti~Application! If the question dot apply fil[ in NA for non
applicable /
NAME (,.~~L~. ~l_~``~(d
PROPERTY ADDRESS _ ~p~/ S M~ S ~~Cr, Permits
SUBDIVISION
Required!!!
1VIECHANICAL
Mechanical Contractor's Narne: /~?~~ C~.~« ; .~~ Business Name: ~U~ 1 a-..~`~~, ,,„ ~ ;~.~.~,.~
`~° ~ ~/~ wr~i~-"r ~`9C~~ City ~ ~ p " ~ ~ 0
Address ~~ ~~ ~ ~ ~ ~~ State 1~ Zi ~~
Contact Phone: (.2 ~~) ~ ~ ~- ~L'v2~ Business Phone: ( )
Email Fax 3 S~ -.~°b~8~
Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace / Exhaust or Vent Ducts
Fumace/Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas-fred appliance
Incinerator System
Boiler
Poo[ Heater
Similar fixtures or Appliances
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat {Circle all that apply) Gas Oil Coa] Fireplace Electric
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature oPl..ie sed Contractor
Required!
~~ ~ 4-.
License number
The City of Rexburg's perm it fee schedule is the same as
Date
the State of Idaho
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