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•
CITY OF REXBURG
MECHANICAL PERMIT APPLICATION Plea
19 E MAIN, REXBURG, ID. 83440 If thi
208-359-3020 X326
PARCEL NUMBER:
SUBDIVISION:
06 00405
4621 Juniper-Cnty Mech ~°~
able
_( We will provide this for you)
UNIT# BLOCK#
(Addressing is based on the information -must be accurate)
LOT#
OWNER:
PROPERTY ADDRESS
PHONE #: Home ( )
bz! ~um~e/'
Work
OWNER MAILING ADDRESS:
EMAIL
CONTACT PHONE #
Cell ( )
CITY: r~ STATE: ~ ZIP
~~O
__
APPLICANT: (If other than owner) ~ s~ e u~ C~~I'frGC~'Jy
(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
CONTRACTOR: yV p2U,~-iDDh''~ i r
MAILING ADDRESS: !". ~d Pax l 93 CITY Ri.9r~y STATE~ZIP 3 ~
PHONE: Home# Work# Cell# `(03 -552(7
EMAIL FAX
How many buildings are located on this property? ~
Did you recently purchase this property? ~1~Yes (If yes give owner's name)
Is this a lot split? ~ YES (Please bring copy of new legal description of property)
PROPOSED USE: sF R
(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 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 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 app4cation 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.
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
FAX
EMAIL
CITY:
FAX
r~
Please complete the entire Application! itt~ gM~tion a~ got apM3- fill In xA for noa appl~stb~e
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!! MECHA~~~ ~
Mechanical Contractor's Name: ~ 2Gt~'iVtd ~, 1~;/~ Business Name: ~~t?An Ql1S~ ~
Address / ~ at Zip
'Contact Phone: ( ) Business Phone: ( )
Email Fax
Mechanical Estimate $ (CommerciaUMulti Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace O Exhaust or Vent Ducts
Furnace/Air Conditioner Combo ~ Dryer Vents
Heat Pump Range Hood Vents
Air Conditioner Cook Stove Vents
Evaporative Cooler 2- Bath Fan Vents
Unit Heater other similar vents & ducts:
Space Heater
Decorative gas-fired appliance
Incinerator System
Boiler
Pool Heater
y Fuel Gas Pipe Outlets including stubbed in or future outlets
~i y~l Inlet Pressure (Meter Supply) PSI
I
Heat (Circle all that apply~as Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on lu ans•
~.~ ~~-
Signature of Licensed. Contractor
The City ofRexburg's
~K~~
License number
schedule is the same as
<~g/l G/o6
Date
the State of Idaho