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America's Family Community
Building Permit No:
Applicable Edition of Code:
Site Address:
Use and Occupancy:
Type of Construction:
Design Occupant Load:
Sprinkler System Required:
Name and Address of Owner:
Contractor:
Special Conditions:
Occupancy:
Certificate of Occupancy
City of Rexburg
Department of Community Development
19 E. Main St. / Rexburg, ID. 83440
one 208) 359-3020 /
06 00207
International Building Code 2003
163E2ndS
Dormitory Housing
Type V-N, Unprotected
7
No
Greenbrier Associates Lmt Prt
P O Box 775
Rexburg, ID 83440
Owner
This Certificate, issued pursuant to the requirements of Section 109 of the International Building
Code, certifies that, at the time time ofissuance, this building orthat portion ofthe building that
wes inspected on the date listed wes found to be in compliance with the requirements of the code
for the group and division of occupancy and the use for which the proposed occupancy wes
classified.
Date C.O. Issued: November 01,,?138~ (03:40P
C.O Issued by:
Building Olrficial
There shall be no further change in the existing occupancy classification of the building nor shall any structural changes,
modifications or additions be made to the building or any portion thereof until the Building Official has reviewed and approved
said future changes.
Water Department: Fire Depa
State of Idaho Electrical
CITY OF REXB URG
-- ..
BUILDING PERMIT APPLICATION PleasE ~
O6 00207 '
19 E MAIN, REXBURG, ID. 83440 If the qu ,~ e
208-359-3020 X326 1 f» E 2nd S-Muhl Famlly Remodel
((.~~ ~~_,~
PARCEL NUMBER:1'1 ~~~'~ ~-"-~ (:~-%`~~.V ~ I ~ ...... --- r--- ~ --- ----- -- ~ ,
SUBDIVISION: UNIT# BLOCK# LOT#
OWNER
is based on the information -must be accurate
CONTACT PHONE # ~ ~~ -- D ~l, ~
PROPERTY ADDRESS: ~~ ~~ ,~_, ~c~~ ~ S ,
PHONE #: Home (~;,~) ~ Work ~~~ `'C~ - ''~~ Cell ( ) ~~lC.~-
~~ ~ <
OWNER MAILING ADDRESS: {~~ Q . ~i'~7 7~.,.-, CITY: } "~' STATE:~ZIP: ~~~
EMAIL {~'K~~ (Ll' ~'1'''l~', ~~~ ;~ 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.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL
PHONE #: Home ( )
Work
CONTRACTOR:
MAILING ADDRESS:
PHONE: Home#
EMAIL
Work#
FAX
CITY:
FAX
Cell ( )
-CITY STATE ZIP
Cell#
IDAHO REGISTRATION #
How many buildings are located on this property? /
Did you recently purchase this property?~N 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: S~G~` ~~ j,~f.-
(i.e., Single Family Residence, Multi Family, Apartments,
Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: under penalty of perjury, I hereby certify that I
have read this application and state_th a information herein is correct and I swear that any information which may hereafter be given by me in heazings before the
Planning and Zoning Commis$icsi or th 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 lic 'hand hereby authorized representatives of the City to enter upon the above-mentioned property for inspections purposes.
NOTE: The building gfftcial ma vok a permit on approval issued under the provisions of the 2000 International Code in cases of any false statement or
misrepresentation of,~ct in th pplicat~ n opon 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.,~'~ ; - f
Signature df Own
~~-~~~~
DATE
Do you prefer to e con>~acted 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 your check does not clear**
2
o~ RExsuRc
~,~ r9 C Y O F
' BUILDING SAFETY DEPARTMENT
U~ ~ IZEXBZJRG
N' 19 E. Main (PO Box 280) Phone: 208-359-3020 x326
ee,
' America's Family Community Rexburg, Idaho 83440 Fax: 208-359-3024
B~~ S H E D ~
www.rexburo.org ianellh rexburg.org
Affidavit of Legal Interest
State of Idaho
County of Madison ~,.
I,
Name
City
Being first duly sworn upon oath, depose did say:
A.
(If Applicant is also Owner of
That I am the record owner of the
permission to:
Name
Address
to submit the accompanying application pe{taining to at property.
B. I agree to indemnify, defend anold Rexburg Ci and its employees harmless from any
claim or liability resulting fro any dispute as to th statements contained herin or as to
the ownership of the property hich is the subject of e application.
Dated this
20
day of
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Address
;ip to B)
described on the attached, and I grant my
3
Please complete the ire Application!
Dwelling Units:
~' If the q e ion does not apply fill in NA for non applicable
NAME x. ~ ~ .~ , .
PROPERTY ADDRES -~ Permit#
SUBDIVISION
SETBACKS
FRONT SIDE
SIDE
Remodeling Your Building/Home (need Estimate) $ "~ _.-- ~}Yf
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area ~/~
Second floor/loft area
Third floor/loft area_
Shed or Barn
Unfinished Basement area -- ~ -~
Finished basement area 1~P
Garage area ._--y --
(30" above
- i; _~
Water Meter Quantity:
**************** Water Meter Size•
Required!!!
.,
PLUMBING ~`~~
Plumbing Contractor's Name: ~ Business Name: f~ ,
Address ,,,31a~ ~ ,~ City Sf~~~~ State ~0
Contact Phone: ( ) ~~~ - `~~a'9 Business Phone: ( )
Email
Fax
~~ ~~
Zip ~.~
FIXTURE COUNT (including roughed fixtures)
L Clothes Washing Machine Sprinklers
~_ Dishwasher ~ Tub/Showers
Floor Drain _~ Toilet/Urinal
Garbage Disposal ~ Water Heater
~-'~ r Hot Tub/Spa ~~ Water Softener
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $ ~~' (Commercial Only)
y ~ ,~~-_ c~ i I ~ ~~~-
uired! Signa o Licensed Contractor License number
The City of Rexburg's permit fee schedule is the same as requir,
/~ -,J-'
Parcel Acres:
BACK
of Idaho
CITYOF REXBURG f 4
Please complete the Mire Application!
,~If the que ion does not apply fill in NA for non applicable
NAME `
. PROPERTY ADDRES Permit#
SUBDIVISION
Dwelling Units:
SETBACKS
FRONT SIDE
Parcel Acres:
Remodeling Your Building/Home (need Estimate) $
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area ~/~ Unfinished Basement area -~
Second floor/loft area --d ~-- Finished basement area jP
Third floor/loft area -y -~ Garage area ..-~ --
Shed or Barn .- y ~ Carport/Deck (30" above grade)Area ~' ~ -~
Water Meter Quantity:
Required!!!
PLUMBING
Plumbing Contractor's Name:
Address
Contact Phone:
Email
Business,N~,a~me: _J l~//J
City ~~r~~~ State ~~
/ ~~ >k~
Zip ~3
- /~11 T Business Phone: ( )
Fax
FIXTURE COUNT (including roughed fixtures)
Clothes Washing Machine
_~ Dishwasher
~ Floor Drain
Garbage Disposal
~~ `~ Hot Tub/Spa
Sinks
(L ki h b
Sprinklers
Tub/Showers
Toilet/Urinal
~_ Water Heater
,_vWater Softener
avatories, tc ens, ar, mop)
Plumbing Estimate $ ' (Commercial Only)
SIDE BACK
Required! 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
**************** Water Meter Size:
4
Please compl,~ete the ent~ Application! If the question ao~t apply fill in NA for non
applicable ~
NAME ` ~ ~ %~ - ~
,PROPERTY AD SS - ~ Permit#
SUBDIVISION
Required!!!
Mechanical Contractor's Name:
Address
Contact Phone: ( )
Email
Business Phone:
Fax
Business Name:
City State
Zip
Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
~' Air Conditioner
7/ Bath Fan Vents
`" ~' '~ Range Hood Vents
~~ ~
Boiler
'r J-- Cook Stove Vents
v `~ Decorative Gas Fireplaces
Dryer Vents
---!? `! Evaporative Cooler
Exhaust or vent ducts
-` ~ `~ Fuel (gas) piping fixtures or appliance outlets
•- J ~ Furnace
'- v~ 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 Licensed Contractor
Required!
The
MECHANICAL
License number
's permit fee schedule is the same as
Date
the State of Idaho
5
• •
REXB UR
C
04
~ ro
CITY OF
~
w
o
~ l~~Vl\~
117 V 1~ BUILDING SAFETY DEPARTMENT
~
s V
~,
19 E. Main St.
Phone: 208-359-3020 x326
'
aa'
e~~ America's Family Community Rexburg, Idaho 83440 Fax: 208-359-3024
SHED ~ VWUW.rexburg.ora janellh@rexburg.org
APPLICATION: "CONSTRUCTION PERMIT"
CONSTRUCTION PERMIT #:_
PERMI'~ APPROVED: YES/ NO
-APPLICANT INFORMATION:
BUSINESS NAME:
OFFICE ADDRESS:
APPROVED BY:
city
OFFICE PHONE NUMBER:
CONTACT PERSON:
-LOCATION OF WORK TO BE DONE:
STREET ADDRESS WHERE WORK WILL BE
BUSINESS NAME WHERE WORK WILL BE [
DATES FOR WORK TO BE DONE:
CONTACT PERSON:
PHONE NUMBER: ( 1
$50.00 FEE PAID: YES/NO
Stat Zip
E PHONE # ( )_
E:
TO
CELL # ( 1
PLEASE CHECK THE TYPE OF PERJ~IT(S) YOU ARE APPLYING FOR:
^ AUTOMATIC FIRE-EXTIN ISHING SYSTEMS
^ COMPRESSED GASES
^ FIRE ALARM AND DE CTION SYSTEMS AND REL ED EQUIPMENT
^ FIRE PUMPS AND R ATED EQUIPMENT
^ FLAMMABLE AND OMMBUSTIBLE LIQUIDS
^ HAZARDOUS MATE IALS
^ INDUSTRIAL OVENS
^ LP-GAS
^ PRIVATE FIRE HYDRANTS
^ SPRAYING OR DIPPING
^ STANDPIPE SYSTEMS
^ TEMPORARY MEMBRANE STRUCTURES, TENTS, AND CANOPIES
APPLICANTS SIGNATURE DATE
...........................................................................................
6
•
EXEMPTIONS FROM STATE REGISTRATION
As of January 1, 2006, the City of Rexburg can no longer sell permits without having a copy of your State
registration number or your exemption from the State registration. Please send a copy of your state registration
or fill out this form showing your exemption and send it with your license renewal or your next permit
application.
(This list is a summarization of Idaho Code Title 54 Chapter 5205, for full definitions of these exemptions
please see the State's website at www.ibol.idaho.gov/cont.htm)
^ Currently State licensed pursuant to Title 54 Idaho Code, Chapters:
3 Architects,
10 Electrical Contractors/Journeyman,
12 Engineers/Surveyors,
19 Public Works Contractors (exempt from fee only registration required),
26 Plumbing/Plumbers,
45 Public Works Construction Management Licensing Act (exempt from fee only registration required),
or
50 Installation of heating, ventilation and air conditioning systems
^ Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit
charitable activity with no wages or salary
^ Employee of a US Government agency (State, City, County, or other municipality)
^ Public Utility doing construction, maintenance, or development to its own business
^ Involved with gas, oil or mineral operations
^ Supplier doing no installation or fabricating
^ Contracting a project or projects with a total cost less than $2000
^ Operation of a farm or ranch or construction of agriculture buildings exempt from Idaho Building Code
^ Any type of water district operations
^ ~ Work in rural districts for fire prevention purposes
Owner who performs work on own property or contracts with a registered contractor to do work as long
as the property is not for resale within 12 months
^ Owner or lessee of commercial property performing maintenance, repair, alteration or construction on
that property
^ Real estate licensee/property manager acting within Idaho Code
^ Engaging in the logging industry
^ Renter working on the property where they live with the property owners approval
^ Construction of a building used for industrial chemical processing per Idaho Code
^ Construeto~ of a modular building (defined by Idaho Code) to be moved out of state
/',
I hereb~ ce th ,.the above information is true and correct to the best of my knowledge.
Print
8
i f
SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete:
Masonry: ~i~"
Roofing: /l/~7
Insulation:
Drywall:
Painting:~/(~~
Floor
Coverings:
Plumbing:
Heating:
Electrical:
.~~'
Special Construction , /~
(Manufacturer or Supplier) ~/
Roof Trusses:
Floor/Ceiling Joists: ~~~'
Siding/Exterior Trim:
Other:
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