HomeMy WebLinkAboutAPPLICATION & DOCS - 06-00344 - Rexburg Surgical Center - Fire SprinklersCITY OF BEXBUAG
BUILDING PERMIT APPLICATION Please c• 06 00344
19 E MAIN, REXBURG, ID. 83440 If the quesd
208-359-3020X326 1~~~y/-~y(~~~~ Surgical Center Sprinkler
PARCEL NUMBER:~~~'~ `~ ~Tl~ (We
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
CONTACT PHONE #
PROPERTY ADDRESS: 3 ~~ ~ y>k ~
PHONE #: Home
Work ( ) Cell
OWNER MAILING ADDRESS: CITY: STATE: ZIP:
EMAIL FAX
APPLICANT (If other than owner)_~~ Uri CZ J~f i~cv.~
(Applicant if other than owner, a statement authorizing applicant to act as agent fox owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS Z5 3 E ` "~` /' CITY: ~K~~~,
ms.eZO.~
STATE; i r~ ZIP fl ~`fyy EMAIL~''~1-~ ~~h ~~ ~, v. ~~ FAX
PHONE #: Home ( ) Work ( ) Cell
CONTRACTOR: ~i9/J~ (a-2P~ ~v``l~Ot~- Ids. ~'~ r ` c>n ~.~vC ~i Dr
MAILING ADDRESS: l Z~ ~ ~ ~~~~ /'Iln•-~Gc CITY C STATE~ZIP ~ `~~
PHONE #: Home (l~~s ,~ `/- ~ 7~~i"17 Work ( ) Cell ~j~ ~.~,~?S~d
EMAIL `~~~~? ~~a ze~ FAX~y~ IDAHO REGISTRATION # & EXP. DATE ~ -/
. Gt'rr ZLL~
How many buildings are located on this property? ~/~ 2
Did you recently purchase this property No % Yes (If yes give owner's name) ~ ~ ~ ~ U t5
Is this a lot split? NO YES (Please bring/copy of new legal description of proper
PROPOSED USE: f~~z~<~e~-~~ ~/ J U L 1 4 2006
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage, Commercial, Addition, Etc
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Unrt~r „~~t~ off n~~rv ti h~~f~ U
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 City of Rexburg shall be tmthful and correct. I agree to comply with all
City regulations and State laws 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 2003
International 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
based. Permit/v//'o~~id if started within 180 days. Permit void if work stops for 180 days.
Signature of Own /Applicant DATE
Do you prefe 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,IanuatX 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. ~ r~
U~~
a0,
e~~ S H E D ~
CITY O F
REXBURG
America's Family Community
BUILDING SAFETY DEPARTMENT
19 E. Main (PO Box 280)
Rexburg, Idaho 83440
www.rex ~burQ.ore
Phone: 208-359-3020 x326
Fax: 208-359-3024
ianellh~.rexb~r¢.orF
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
Address
City State
Being first duly sworn upon oath, depose and say:
A.
(If Applicant is also Owner of Record, skip to B)
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 herein 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:
3
•~
Please complete the entire AppLtcation!
If the question does not apply fill in NA for non appGcabk
NAME
PROPERTY AD SS ,~~/ rti Permit#
SUBDIVISION
Dwelling Units: Parcel Acres:
SETBACKS
FRONT SIDE SIDE BACK
Remodelltlg Your Buildrrlg/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 Finished basement area
Third floor/loft area Garage area
Shed or Barn Carport/Deck (30" above grade)Area
Water Meter Quantity:
Required.!!
PLUMBING 6~uv,-'~c~ ~"°`~'~
_J
Plumbing Contractor's Name: .~~e ~~ee[L ~*f.~- ~~St~uni(if Name:~~i~~
s ess
Address. ~'Z 5 3 ~ ~/~~~` ,/~~- City ~ r State //~ Zip ~3 y'-~O
Contact Phone: (Z°~ ?a ~`r 9 7~o Business Phone: (2~ ~ ~ 9b ~- ~T~'~
Email ~~%v~•~~..- ~n~e /r: ~e~.~y2Sn . Co..~-•
FIXTURE COUNT (including roughed ftartures~
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks (Lavatories, kitchens, bar, mop)
**************Water Meter Size: ~
_.~ Sprinklers
Tub/Showers
Toilet/Urinal
Water Heater
Water Softener
Plumbing Estimate $ ~0~ (Commercial Only)
of Licensed Contractor
The City of
R~7= ~~ 98" //`z 9~ 7
License Number& Expiration D e
wit fee schedule is the same as rzquired by the State
7~iy-~~
Date
Idaho
4