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G~TY OF REXBURG
MECHANICAL PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X326
Please 06 00238
If theque 1010 Hillview Dr-Cnty Mech
PARCEL NUMBER: ~ ~~ ~(~`~ (We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
OWNER: ,~ ,-~~y'!~ ,~~ L~~^~/ CONTACT PHONE # Lc,1~/~ - Uo~~~_
PROPERTY ADDRESS: ~~~~~~ ~ ~ •
PHONE #: Home ( )lp'(Jo1r~~ Work
OWNER MAILING ADDRESS: ~' CITY:
~~~'J~
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.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP
PHONE #: Home
Work ( )
Cell
Cell ( )
CONTRACTOR:
MAILING ADDRESS: ~~/~/ ~ j~ ,~ CITY
PHONE: Home#,3.~ ~J'~ Work#
EMAIL
EMAIL
STATE: ZIP:
CITY:
FAX
FAX
Cell# ?f ~ ~// 7e~
'ATE // ZIP ~~O
How many buildings are located on this pro ? /
Did you recently purchase this property No es (If yes give owner's name)
Is this a lot split~~ YES (Please bring copy of new legal description of property)
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 I sweaz that any information which may hereafter be given by me in heazings 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 appl' ation and hereby authorized representatives of the City to enter upon the above-mentioned property for inspections purposes. NOTE: The
building official m re ke a permit on approval is ed under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the application or n plans on which th a approval was based. Permit void if not stazted within 180 days. Permit void if work sto~ps~fo~r 180 d/ays~.
Signature O er/Applicant ITATE
Do you prefer to be contacted b 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
Please complete the
a~~l~alble
entire Application!
NAME ~~ ~ O-~
PROPER Y ADDRESS ~~~~/
SUBDIVISION
Permit#
Required!!! MECHANICAL
Mechanical Contractor's Name: / ^ ~/'' Business Name: ~ ~~~~,~~~ ~/~
Address ~~17 G~ ~~~~ ity ~~ * State ~ Zip~~
Contact Phone: ( ) Business Phone: ( ) ~j/~-G//~~
Email
Fax
If the question does not apply fill in NA for non
Mechanical Estimate $z~~~~CommerciaUMulti Family Only)
FIXTURES & APPLIANCES 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
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply Gas it Coal Fireplace Electric
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature of Licensed ontractor icense number Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho