HomeMy WebLinkAboutAPPLICATIONS, BP - 06-00419 - 544 Golden Willow Dr - ShedZ
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CITY OF KEXB UI~G • T ~ •
PERMI
BUILDING PERMIT APPLICATION Please c
19 E MAIN, REXBURG, ID. 83440 If the questi ~6 00419
208-359-3020 X326 1 ~ 544 Golden Willow Dr-Shed
PARCEL NUMBER: ~~~1~~/r,~ L~~~ (We
SUBDIVISION: j~ %l Ll ~:.., K~~ k~ UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
CONTACT PHONE # ~~1- ~S7 -
PROPERTY ADDRESS: ~~~. S . Ga ~s'7~C.- ~~ ~w ;~i'L~-e
PHONE #: Home ( ) Work
Cell (7~~ ~~ / ~ 75,~~
OWNER MAILING ADDRESS: t S-Z ~~ 3 oar.:/ . CITY: /~_STATE~ d? ZIP: ~ ~f~~,
EMAIL c~~r; ! !~!~ ~ .~~'./~ , ~'~ti,_ FAX (~ ~1 6 SZ~ - vi 6
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent fox owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR:
MAILING ADDRESS: CITY STATE ZIP
PHONE #: Home ( ) Work
Cell
EMAIL FAX IDAHO REGISTRATION # & EXP. DATE ° ~'~
How many buildings are located on this property?.
Did you recently purchase this property?~ Yes (If yes give owner's name)
Is this a lot split? ~ YES (Please bring copy of new legal description of property)
PROPOSED USE: ~~~`~
(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
hearings 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~'ermit void if not started within 180 days. Permit void if work stops for 180 days.
of Ownex/Applicant
CITY:
~° /~ /Q~
DATE
Do you prefer to be contacted by fax, email or one Circle One
WARNING -BUILDING PE MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non-refundable and are paid in full at the time of application beginning January Z 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*'k
2
Builc~g Safety Department
City of Rexburg
19 E. Main janellhQrexburg.org Phone: 208.359.3020
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
~~ ¢E7CB[t~~,
.~ fo ci~rv or
U.) ~ G i W~~~~V
A
.. .._ t~ ...._.........
America's Family Cammuniry
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
City
State
Being first duly sworn upon oath, de se and say:
(If Applicant is also Owner of ord, skip to B)
A. That I am the record owner of the prop described on the attached, and I grant my
permission to:
Name Address
to submit the accompanying application pertaining to tha rol
B. I agree to indemnify, defend and hold Rexburg City an.
claim or liability resulting from any dispute as to the sta
ownership of the property which is the subject of the a
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:
Address
employees harmless from any
ants contained herein or as to the
3
Please com lete the .tire A lication! •
p PP
If the question does not apply fill in NA for non applicable
NAME ~,~>~ (~;f~>~.ll
PROPERTY ADDRESS ~'~1'" S- G ef~r.. ~,'~tv ~-.~ /,~~~~ Permit#
SUBDIVISION G~ ~t.1 ~a R .~-.,rr:
Dwelling Units: Parcel Acres:
SETBACKS 1 1
FRONT SIDE SIDE ~ ~ BACK '
Remodeling Your Building/Home (need Estimate) $
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area Unfixushed Basement area
Second floor/loft area Finished basement area
Third floor/loft area Garage area
Shed or Barn ~4' ~ ~ ~ ~ Carport/Deck (30" above grade)Area
Water Meter Quantity:
**************Water Meter Size:
Required!!!
PL U1VIBING
Plumbing Contractor's Name: Business Name:
Address City State Zip
Contact Phone: ( ) Business Phone: ( )
Email
FIXTURE COUNT (including roughed fixtures
Clothes Washing Machine Sprinklers
Dishwasher Tub/Showers
Floor Drain Toilet/Urinal
Garbage Disposal Water Heater
Hot Tub/Spa Water Softener
Sinks (Lavatories, kitchens, bar, mop)
Plumbing Estimate
(Commercial Only)
Signature of Licensed Contractor
The City o~
License Number& Expiration Date Date
t fee schedule is the same as required by the State of Idaho
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