HomeMy WebLinkAboutAPPLICATION - 06-00273 - Porter Park - Splash Park & RestroomsCITY OF REXB URG
BUILDING PERMIT APPLICATION Please c. 06 00273
19 E MAIN, REXBURG, ID. 83440 If the questi~ Slash Park & Restrooms
208-359-3020 X326 p
PARCEL NUMBER:.{`~~~~~~z~, (We wut proviue uus ic.,r y~u~
SUBDIVISION: UNIT# BLOCK# LOT#
Addressin is based on the information -must be accurate
OWNER NAME.• r; y o ~ x >1-~ q CONTACT PHONE # 3 S l- 3a Z a
PROPERTY ADDRESS: 2 5 ~ W 2"~ S Re 6aT;.,~n ~~yyo
PHONE #: Home ( ) ~A' Work (Zo`~) 3~"~ 3oZ0 Cell ( ) ~ ~~
OWNER MAILING ADDRESS: ~ Z ~ ~t n'~c r I~ CITY: ~e~c~u~_STATE:~ZIP: 8` 3 D
EMAIL /(~~ FAX 3 ~~ " 3 0 ~ _I
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
STA
CITY:
IP EMAIL F
PHONE #: Home
Work
Cell
CONTRACTOR: 3- f 'l Lo n S f r ti c f ~' o~ L L L
MAILING ADDRESS: 3 9 Z /V. ~2lX) 1/I~, CITY e C ~! ro STATE~~ZIP_
PHONE: Home# /V A' Work# 3S 1-Z3 ~ ~ Cell# fi `~ 5' ~~/3 Fax# 3 S y'- ~ 5
EMAIL 1V IDAHO REGISTRATION # & EXPIRATION DATE l ~! 6 ~ y'A-~~y ~~'
How many buildings are located on this property?~
Did you recently purchase this property? To Yes (If yes give owner's name)
Is this a lot split? ~ YES (Please bring copy of new legal description of property)
PROPOSED USE: ~a~e ~c ict
(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 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 Ciry of Rexburg shall be truthful and correct. I agree to comply with all Ciry regulations and State laws relating
to the subject matter of this applica ~on and hereby authorized representatives of the Ciry to enter upon the above-mentioned property for inspections purposes. NOTE:
The b ' racial may revoke a emut on approval issued under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact
e applic nor on the plans n which the permit or approval was based. Pernvt void if not started within 180 days. Permit void if work stops for 180 days.
~/ 3a / a ~
Signature of Owner/Applicant 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 JanuanTZ 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**
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O4 REXB URC •
~~ r~ CI OF
s'• ° BUILDING SAFETY DEPARTMENT
U~ ~ REXBURG
~' 19 E. Main (PO Box 280) Phone: 208-359-3020 x326
a~ America's Family Community Rexburg, Idaho 83440 Fax: 208-359-3024
a~~SNEO \0
www.rexbure.ore ~ellh~a,rexburg.o~re
Affidavit of Legal Interest
State of Idaho
County of Madison
I, ,
Name Address
City State
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
A. That I am the record owner of the property described on the attached, and I grant my
permission to:
Name Address
to submit the accompanying application pertaining to that property.
B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any
claim or liability resulting from any dispute as to the statements contained herin or as to the
ownership of the property which is the subject of the application.
Dated this day of , 20
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
•
Sprinklers
Tub/Showers
Toilet/Urinal
Water Heater
Please complete the entire Application!
If the question does not apply fill in NA for non applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Dwelling Units: Parcel Acres:
SETBACKS
FRONT
'~~ `' " ~~~~' ' r `~ ~~* Water Meter Size:
Remodeling Your Building/Home (need Estimate) $
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area / d 3 (o Unfinished Basement axes
Second floor/loft area Finished basement area-
Third floor/loft area Garage area
Shed or Barn Carport/Deck (30" above
Water Meter Quantity:
Required ~~!
PLUMBING
Plumbing Contractor's Name: Business Name:
Addres
Ciry
Contact Phone: ( ) Business Phone: ( )
Email Fax
FIXTURE COUNT (including roughed fixtures
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $ ~ 9 0 ~ (Commercial Only)
`P~i4~ ~ - r 4 ~~
Required! Signatur of ~ ~censed Contractor
The City of Kexbu
Permit#
Water Softener
~{3~~~~
License number
schedule is the .came as
by the State
Date
SIDE SIDE BACK
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Please complete the enti~Application! if the question does apply 5ll in NA for non
applicable
NAME
PROPERTY ADDRESS Permit#
SUBDIVISION
Regz~ired ~~!
MECHANICAL
Mechanical Contractor's Name: Business Name:
Address City
Contact Phone: ( ) Business Phone:
Mechanical Estimate $ ,2 ~ ~ ~ (Commercial/Multi 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
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Avvlication
Point of Delivery must be shown on plans.
Required! Signature of Licensed Contractor
The
License number
schedule is the .came as
Date
the State of Idaho
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