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CITY OF REXBURG 06 00392
MECHANICAL PERMIT APPLICATION Plea ,n ~
19 E MAIN, REXBURG, ID. 83440 If the 724 Lupine St-Mechanical Ible
208-359-3020 X326
PARCEL NUMBER: ~}~(ZXl ~~_( We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
CONTACT PHONE # 313- c3' ~
PROPERTY ADDRESS: ~~~ L~P~'~1-~ R~k~t ~ y, ~-h
PHONE #: Home (~$) 3(~-d3g~ Work (206) 3SG- Q`~`~'i Cell (~g) X09- xg5
OWNER MAILING ADDRESS:.? a y ~, vn,'~ CITY: ovr • STATE:T.L~ ZIP: g~k/o
EMAIL FAX
APPLICANT: (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL
PHONE #: Home
CITY:
FAX
Work ( )
Cell
CONTRACTOR:
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
Clow many bulldmgs are located on this property?
Did you recently purchase this property? i~ Yes (If yes give owner's name)
Is this a lot split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE: ~
(i.e., Single Family Residence, Multi
Apartments, Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: under penalty of perjury, I hereby certify that I have
read this application and state that the information herein is correct and I swear that any information which may hereafter be given by me in heazings before the Planning
and Zoning Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply with all City regulations and State laws relating to the
subject matter of this application and hereby authorized representatives of the City to enter upon the above-mentioned property for inspections purposes. NOTE: The
building official may revoke a permit on approval issued under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the application or on the plans on which the permit or approval was based. Permit void if not stazted within 180 days. Permit void if work stops for 180 days.
d$ l0$ lv6
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 January 1.2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval
Please complete the entire Application! Ir tl~e yuestiun aoea oot apply rl in NA for ~~ •pplicabk
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!!
Mechanical Contractor's Name:
Address
Contact Phone: ( )
Email
Business Name:
_City State
Business Phone: ( )
Fax
Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
Furnace/Air Conditioner Combo Dryer Vents
Heat Pump Range Hood Vents
Air Conditioner Cook Stove Vents
Evaporative Cooler Bath Fan Vents
Unit Heater other similar vents & ducts:
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
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
Zip
Mechanical Sizing Calculations must be submitted with Plans & A>plication
Point of Delivery must be shown on plans.
Signature of Licensed Contractor
The City of Rexburg's
License number
Date
fee schedule is the same as required by the State ofldaho
MECHANICAL