HomeMy WebLinkAboutAPPLICATION, BP - 06-00418 - 1095 W 14th N - MechanicalZ
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CITY OF REXBURG
MECHANICAL PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X326
PARCEL NUMBER:
SUBDIVISION:
_( We
UNITi
(Addressing is based on the information -must be accurate)
06 00418
1095 W 14th N-County Mech
OWNER: TACT PHONE #
PROPERTY ADDRESS: ~~~~~L-tJ ~ c
PHONE #: Home ~~) ~ ^~Work ~~~Z ~w~~Cell ( ) ~-
OWNER MAILING ADDRESS:~~ °jt~~ f ~TY: ~ - STATF,~ZIP:~~~
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 ( ) Work
Cell
CONTRACTOR:
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL
FAX
How many buildings are located on this property? /
Did you recentlypu-rchase this propert No Yes (If yes give owner's name)
Is this a lot split`X.~v~y YES (Please bring copy of new legal d cription of property)
PROPOSED USE: ,~~u ~ ~CJ~~
(i.e., Single Family Residence, Multi Family, Ap ts, 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 application or o e 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.
~; ZS--~~
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
PERMIT #
Please complete the entire Application!
If the questic -
CITY:
FAX
Please complete the entire Application!
NAME ~
PROPER Y ADDRE O _
SUBDIVISION ~
Business Name: ~ ~~f
Required!!!
Mechanical Contractor's Name:
Address- ~(~ `~ ~~~ ~~~~ ~ City ~ </ State Zip ~~~~o
Contact Phone: (~~~ .5~2_ ~~y ~,~ Business Phone: ) j
Email
If the question does not apply fill in NA for non applicable
Permit#
Mechanical Estimate $ (Commercial/Multi Family Only)
FIT S & APPLIANCES COUNT (Single Family Dwelling Only)
ce 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 ap ) Gas Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature of Licensed Contractor
The
License number
's permit fee schedule is the same as
the State of Idaho
Date