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CI7.Y Off' AEXB UKG
BUILDING PERMIT APPLICATION P1
06 00427
19 E MAIN, REXBURG, ID. 83440 If 1 216 1V 1St L' -Shed
208-359-3020 X326 q ~ (~l~
PARCEL NUMBER ~ r 1~~ (~~ ~,,~~F cJ~[ U (We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
ion!
~icable
CONTACT PHONE # E~~ ~ % ~- % 7 3 ~S °
PROPERTY ADDRESS: ,~ /L~ /V / S,T ~~1 ~ T /~~ ~~~i clJpC~, .~L C'~~19~~ ~f'~ Li°~~
PHONE #: Home (x) ~3 .may- ~i 7 .~ .5~X1ork ( ) ~'` /'~ Cell ( ) /L'/~
OWNER MAILING ADDRESS:/~/V/.S ~` r,~~S~r CITY: ~. v STATE:.~~ ZIP: ..~~1G
EMAIL z~',~s~ FAX ,~,~„~
APPLICANT (If other than owner) ,!I/~/~
(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 F
PHONE #: Home
Work
Cell
CONTRACTOR:
MAILING ADDRESS: ~JrJU I S -J aiD V~Ie~- CITY ~~-}~'I-LIY,QVi.'I'l/ STATE~~ZIP ~C~
PHONE #: Home (~) ~~'~3 Work ( ) Cell ( )
EMAIL FAX $DI.26`~' ~°~ IDAHO REGISTRATION # & EXP. DATE 25I 7$ 7 7I31~,;
How many buildings are located on this property?
Did you recently purchase this property? No f Yes (If yes give owner's name)
Is this a lot split? NO YES (Plea/se brin/g copy of new legal description of property)
PROPOSED USE: ~ ~,,cy ~ S+h a f~
(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 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 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. tl'~it void if not started within 180 days. Perrnit void if work stops. for 180 days.
- - / /_
Signature of caner/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, anuar~l. 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**
CITY:
2
Build g Safety Department ;o REXaUq~,o CITY O F
City of Rexburg ~ 's V~
'' ~ ~ ~1L1~ V 1tG
19 E. Main janellhQrexburg.org Phone: 208.359.3020 America's FamilyCommuniry
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 ~'"E° ~"~~
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
Address
City ~ State
Being first duly sworn upon oath, depo e and say:
(If Applicant is also Owner of R cord, skip to B)
A. That I am the record owner of the pro erty described on the attached, and I grant my
permission to:
Name address
to submit the accompanying application pertaining to at property.
B. I agree to indemnify, defend and hold Rexburg Ci and its employees harmless from any
claim or liability resulting from any dispute as to the tements contained herein or as to the
ownership of the property which is the subject of the a lication.
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 'com lete the •ire A lication!
P pp
If the question does not apply fill in NA for non applicable
NAME (~.~~~~('~ Cz~~~~..c ~ ~ S P
PROPERTY ADDRESS ~,~ / ~ /1/ f .f ~ f_- ~ f 7`- fi`t' ~Jt ~ v /~ G- ~ c/~ s yyPermit#
SUBDIVISION ,~i:!
Dwelling Units: Parcel Acres:
SETBACKS
FRONT ~C ~ SIDE ~ ~ ~ SIDE ~ BACK ,~C' /
CIn
Remodeling Your Buildirsg/Home (need Estimate) $~~ ~,~~ '-'
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Axea Unfinished Basement area
Second floor/loft area Finished basement area-
Third floor/loft area Garage area
Shed or Barn ;5,? ~ Caroort/Deck (30" above
Water Meter Quantity: ~ **************Water Meter Size:
Required.!!
PLUMBING
Plumbing Contractor's Name: ,~ ~ Business Name:
Address City State Zip
Contact Phone: ( ) Business Phone: ( )
Fax
FIXTURE COUNT (including roughed fixtures
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks (Lavatories, kitchens, bar, mop)
Plumbing Estimate $ (Commercial Only)
Signature of Licensed Contractor
The City o/
Sprinklers
Tub/Showers
Toilet/Urinal
Water Heater
Water Softener
License Number& Expiration Date Date
t fee rchedule is the .came as required by the State of Idaho
4
•
Please Complete the entire AppllCatlOn~ If the question does not apply fill in NA for non
applicable
NAME V ~Cf ~ Cr ~ . T ~ L~ ~ S'~ ~~
PROPERTY ADDRESS ,;~ /E' /1/ 1,5.E ~_ .~1~5~' ~~ x ~j 4~ ti'C4 Permit#
SUBDIVISION ,~%%
Required ~~!
Mechanical Contractor's Name:
Addres
Contact Phone: ( )
Name:
City State Zip
s Phone: ( )
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace 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 apply) Gas Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calcularions must be submitted with Plans & Aynlication
Point of Delivery must be shown on Mans.
Signature of Licensed Contractor License number Date
The City of Kexburg's permit fee schedule is the same ar required by the State
MECHANICAL
5
•
SUBCONTRACTOR LIST
Excavation & Earthwork: ~ r ~ ~ ~ ~ -~ c,~f~ ~- (~ l -.~~~
Masonry:~,l~
Roofing: / ~~ /~~ 5~ h.e ~~
Insulation: .5 ~L, ~ ~ ~ ~± ~ r,~ G t- • (,c,3 ~' S .z
Drywall: f~~/~1
~---
Painting: ~ [ e ~~5. ~
Floor
Coverings: ~G~/~
Plumbing: /~~~
~ .,
Heating:~f~,~' G-z L,J ~ S~~e
Electrical:~~ @ ~, ~ ~. ~ ~ / ~~R
Special Construction
(Manufacturer or Supplier)
Roof Trusses: ~ /~j' ,~ ~~
_~--~
Floor/Ceiling Joists: / e: ,~~' ~t~z c~
------
Siding/Exterior Trim: ~ y~~ 5~.~-~
i s
' ~ ~ EXEMPTIONS FROM STATE REGISTRATION
As of January 1, 2006, the City of Rexburg can no longer sell permits without having a copy of your State
registration number or your exemption from the State registration. Please send a copy of your state registration or
fill out this form showing your exemption and send it with your license renewal or your next permit application.
(This list is a summarization of Idaho Code Title 54 Chapter 5205, for full definitions of these exemptions please
see the State's website at www.ibol.idaho~ov/cont.htm)
^ Currently State licensed pursuant to Title 54 Idaho Code, Chapters:
3 Architects,
10 Electrical Contractors/Journeyman,
12 Engineers/Surveyors,
19 Public Works Contractors (exempt from fee only registration required),
26 Plumbing/Plumbers,
45 Public Works Construction Management Licensing Act (exempt from fee only registration required), or
50 Installation of heating, ventilation and air conditioning systems
^ Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit charitable
activity with no wages or salary
^ Employee of a US Government agency (State, City, County, or other municipality)
^ Public Utility doing construction, maintenance, or development to its own business
^ Involved with gas, oil or mineral operations
^ Supplier doing no installation or fabricating
^ Contracting a project or projects with a total cost less than $2000
^ Operation of a farm or ranch or construction of agriculture buildings exempt from Idaho Building Code
^ Any type of water district operations
^ Work in rural districts for fire prevention purposes
`~ Owner who performs work on own property or contracts with a registered contractor to do work as long as
the property is not for resale within 12 months
^ Owner or lessee of commercial property performing maintenance, repair, alteration or construction on that
property
^ Real estate licensee/property manager acting within Idaho Code
^ Engaging in the logging industry
^ Renter working on the property where they live with the property owners approval
^ Construction of a building used for industrial chemical processing per Idaho Code
^ Construction of a modular building (defined by Idaho Code) to be moved out of state
I here~y~tify that the above information is true and correct to the best of my knowledge.
Signature `~ Date
~~,~ G ~- • ~ • r.~ ~'s~ ~
Print Name
7
Please complete the ent~ AppliCatiOri! If the question doe~t apply fill in NA for non
applicable
NAME ~_C~ ~l~' ~
PROPERTY ADDRESS ~ / ~ ti / S i ~
SUBDIVISION
06 00427
216 N 1st E-George Wiser
Requlred!~~
ELECTRICAL
Electrical Contractor's Name G ~,~~ ~ ~~ Business Name
Address City,
Cell Phone ( ) Business Phone
Fax
to Zip
Electrical Estimate (cost of wiring & labor) $ (Commercial/Multi Family Only)
TYPES OFINSTALLATION-RESIDENTIAL
(New Residential includes everything contained within the residential structure and attached garage at the same dme)
c/ Up to 200 amp Service*
201 to 400 amp Service*
Over 400 amp Service*
Existing Residential (# of Branch Circuits)
Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year)
Spa, Hot Tub, Swimming Pool
Electric Central Systems Heating and/or Cooling (when not part of a new residential construction permit
and no additional wiring)
Modular, Manufactured or Mobile Home
Other Installations: Wiring not specifically covered by any of the above
Cost of Wiring & Labor: $
Pumps (Domestic Water, Irrigation, Sewage)
Requested Inspections (of existing wiring)
Temporary Amusement/Industry
*Includes a maximum of 3 inspections. additional inspections charged at requested inspection rate of $40 per hour.
r
r'_ ._ ,~ o ~~. ..4..
Si afore of Licensed Contractor ~^TLicense number
The
schedule is the came as
~/i/ c ~
Date
the State of Idaho
6