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OC NTH w ~ ;~ 7 ~ ~ W y fq ? ~ r z v mZ~ o ~° ~ Z p m .~ o ~ ~ ~ io Z ~ ~ ~ a ~ y ~ C7 Z O N O ~ eo a City.of Rexburg/ 11~adis,~ County Din' RT ,~ T BUILDING PERMIT APPLICATION i~_ ._ ~~ ~= Q 6 Q ~ 2 2 5 19 E MAIN, REXBURG, ID. 83440 ~ ~ ~. ~ ~ *. ; Zos-3s9-3o2o x322 3915 W 2000 N-Casty Mech PARCEL NUMBER:~~c~~"~l.~~O 10~ ~ L~ SUBDIVISION: Utz,. ~ ~ tiLUCK# LOT# (Addressing is based on the information -must be accurate) ~J~A-t~,~~ ~~ ,~~-, ~? _ CONTACT PHONE # OWNER MAILING ADDRESS: 3`1 i 5 ~ Z~~a ~ CITY: ~X~ .~, STATE ~~ ZIP:_~~8 EMAIL FAX APPLICANT: (If other than owner) " (Applicant if other than owner, a statement authorizing applit~itt to act as agent for owner mast accompany this application.) APPLICANT INFORMATION: ADDRESS CITY: STATE; ZIP EMAIL FAX PHONE #: Home ( } Work ( } Cell ( ) CONTRACTOR: SyS, ~<.~ ~ ~~ ~ MAILING ADDRESS: 3~~ Y ~ ~ ~~ N CITY~Z STATE~© ZIP ~~~ PHONE: Home# ~~l,S~-~y~ Work# Cell# ~ ~' ~ - Y z ~ 7 EMAIL FAX How many buildings are located on this property? t Did you recently purchase this property? No Yes (If yes give owner's name) Is this a lot split? ~ 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, l hereby certify that t have read this application and state that the informaEion herein is correct and I swear that any infomtatia~ which may hereafter be given by me in hearings before the Plamting and Zoning Commission or the City Couner7 for the City of RexMag shall be ttudtful and corrax. I agree w canply with all City regulations and State laws relating to the subject matter of this application and hereby authorized rept+aset~ives of the City to enter opal the above-mentioned properly for inspections purposes. NOTE: The building official may revoke a permit oxt approval issued under the provisions of the 2000 htOanationai Code in ernes of arty 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. / / Signattue of Owner/Applicant DATE Do yogi prefer to be contacted by fax, email or phone? Circle One WARNING - BUII,DING PERMIT MUST BE POSTED ON CONSTRUCTION Sr1'EI Plan fees are non-refundable and are paid in full at the time of application beginning ,Tarnaarv I.200S. City of Rexburg's Acceptance of the plan review fee does not constitute plan approval. 2 PHONE #: Home (~~) ~ S~ - 7 ~ o ~ Work ( ) Cell { ) ~~~iTS~~ COIYl~~~t'~@ t~le ~n~ .I~~~~~1Ca$[Cill~ It'the yuestioza cla~ot .~pt~ly t. "~iA ti~z• xi~~i~ a~plic.~i.~le NAME PROPERTY ADDRESS SUBDIVISION Permit# Rec~u ~VIEC.h~~1VICA~ Mechanical Contractor's Name: ~~ STi~y ~/~-~- Business Name: S ~. ~ Address 3 l d ~ ~' l J ~ ~u City_ ~ (~ ~ ~ State ~ ~ Zip~~ Contact Phone: ( ) `7 YS--~ ~FY( Business Phone: ( ) 35~ - 4/Z~ ~ Email Fax Mechanical Estimate ~ ~CommerciaUMnlti Family Only) FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only) Furnace ~ Exhaust or Vent Ducts Furnace/Air Conditioner Combo 3 ` ~_ Dryer Vents ' s Heat Pump Air Conditioner Evaporative Cooler Unit Heater Space Heater Decorative gas-fired appliance Incinerator System Boiler Pool Heater Similar fixtures or Appliances Range Hood Vents Cook Stove Vents `> Bath Fan Vents 'L~ other similar vents & ducts: ~ Fuel Gas Pipe Outlets including stubbed in or future outlets ~ Inlet Pressure (Meter Supply) PSI Heat (Circle all that apply) ~ Oil Coal Fireplace Electric Mechanical Sizing Calculations mast be submitted with Plans & Application Point of Delivery must be shown on plans. ~ ~--a Signature ul' f,icensed Contractor License number Date Rey iE n•s;d? The City of Rexburg's permit fee schedule is the same as required by the ,State of Idaho 3