HomeMy WebLinkAboutAPPLICATION, BP - 06-00431 - 50 N 4th W - ShopZ
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CITY OF KEXB U1~G
000431
BUILDING PERMIT APPLICATION Please 50 N 4th W -Shop
19 E MAIN, REXBURG, ID. 83440 If the qu
208-359-3020 X326 {~
PARCEL NUMBER:I~-~~~-~~I D~~~ (We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
OWNER NAME: Oti J 6 ~ ~4 e CONTACT PHONE # .? ~ S 3 SCP -7 7
PROPERTY ADDRESS: SO N, ~ ~ Lt~6S T
PHONE #: Home ~20~ 3s lP 778 Work fgo~ ~r~9lo -~8'~~ Cell~Bf 3/3- O/3$
OWNER MAILING ADDRESS: J"D /V ~ ~T~j G(~,e~~CITY: E~($itRG' STATE-~ ZIP: S~S~S~~
EMAIL I3L,~4 G~ ~ ~° ~BLe oNe _ Ne7" FAX
APPLICANT (If other than owner) a/f~
(Applicant if other than owner, a statement authorizing applicant to act as agent fox owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS CITY:
STATE; ZIP
PHONE #: Home ( )
EMAIL F
Work ( )
CONTRACTOR:
MAILING ADDRESS: _ _ CITY,. ,~,L STATE ZIP_ ~ '~
PHONE #: Home
EMAIL F
Work ( ) Cell
IDAHO REGISTRATION # &I~
How many buildings are located on this property? bill E
Did you recently purchase this property? ~ Yes (If yes give owner's
Is this a lot split?O YES (Please b
PROPOSED USE: ~aRR9 ~
(i.e., Single Family Residence, Multi Family, Apar
copy of new legal description of
Cell ( )
- 5 2006
F REXBURG
Remodel, Garage, Commercial, Addition,
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 ap~proval i~ssued u 3
International Code in cases of any false statement or misrepresentation of fact in the application or on 191"sly' ~ ~ ~r fapr ~ s
based. Permit void if nnistarted within 180 days., Permit void if work stops for 180 days
d8'/ 3~/:
Signature of Owner/Applicant ~-1T'~+
Do you prefer to be contacted y fax, email or phone? Circle One
WARNING -BUILDING PERMIT MUST BE POSTED ON CO TRU T O ~ ~~---
Plan fees are non-refundable and are paid in full at the time of application e
City of Rexburg's Acceptance of the plan review fee does not cons tut p 1
**Building Permit Fees are due at time of application** **Building Permits are r our c eck does not clear**
2
o. ., ~~
m~~
00,
B~~sH eo
•
CITY O F
REXI3URG
America's Family Community
•
BUILDING SAFETY DEPARTMENT
19 E. Main (PO Box 280) Phone: 208-359-3020 x326
Rexburg, Idaho 83440 Fax: 208-359-3024
www.rex ~burQ.orQ janellhCa~rexburg.o~re
Affidavit of Legal Interest
State of Idaho
County of~Madison
,..,~
I, ~~ ,
Name ~''
City
Address
State
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip o B)
A. That I am the record owner of the property d scribed on the attached, and I grant my
permission to:
Name
of
to submit the accompanying applicati pert ~ ~ g to that property.
B. I agree to indemnify, defend and 1 exburg City and its employees harmless from any
claim or liability resulting from any spute as to the statements contained herein or as to the
ownership of the property which i subject of the application.
Dated this
Subscribed and sworn to
Signature
Address
20
me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
3
Plea e c m let th •'r A li ati n! •
s o p e ee a pp c o
~t If the question does not apply fill in NA for non applicabk
NAME C~ oRDO/lJ J ~Gl~ GI'C
PROPERTY ADDRESS S~ ~L'. `7'~J~i ltJ~S T Permit#
SUBDIVISION /l~f~
Dwelling Units: ~~" Parcel Acres:
SETBACKS
FRONT SIDE AFT SIDE BACK ~ ~= r
Remodeling Your Building/Home (need Estimate) $ /~ /4
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area Unfinished Basement area
Second floor/loft area Finished basement area
Third floor/loft area Garage area '~'tg
Shed or Barn Carport/Deck (30" above g de)Area
Water Meter Quantity:
~'
**************Water Meter Size: /Y
Required!!!
PLUMBING
Plumbing Contractor's Name: ~ Business Name:
City State Zip
Contact Phone: ( )
Business Phone: ( )
FIXTURE COUNT (mcludingroughed fixtures
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks (Lavatories, kitchens, bar, mop)
Plumbing Estimate $.
(Commercial Only)
Sprinklers
Tub/Showers
Toilet/Urinal
Water Heater
Water Softener
Signature of Licensed Contractor License Number& Expiration Date Date
The City of Itexburg°r~iermitfee rchedule it the name as required by the State of Idaho
4
Please Complete the eritlfe AppllcatlOnZ If the question does not apply fill in NA I'or non
applicable
NAME w R p oN J, .~Lff G I~
PROPERTY ADDRESS SO /1/. hl T~ ~t1.GS ~ Permit#
SUBDIVISION it(/4
Requi~ed.~~~ MECHANICAL
Mechanical Contractor's Name: / 1/ ~ Business Name:
Address City State Zip
Contact Phone: ( ) Business Phone: ( )
Email Fax
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
Mechaxvical Sizing Calculations must be submitted with Plans & Aflvlication
Point of Ueliverv must be shown on t
Signature of Licensed Contractor
The
License number
schedule is the ,came as
Date
the State of Idaho
5
• •
SUBCONTRACTOR LIST
Excavation & Earthwork
Concrete: /U~
Masonry: /~
Roofing: mil' ,~A' `'
Insulation: /'~
Drywall: /~/
Painting: l V /~
Floor ~~
Coverings: A ~ ,,Q_
Plumbing: / V ~ 1
Heating: ~ V ~' T" .
Electrical:
Special Construction
(Manufacturer or Supplier)
Roof Trusses: /~ !'1~ ~ (~ L S ~ ~17 i¢/f~0 ~"~ GL s , ,L_~
- ~.
Floor/Ceiling Joists:
Siding/Exterior Trim:,
Other:
~~
l L ~' a ,~ I o~ ~ /~ 5 ~~ ?C'{.~ ~c i.;
6
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.gQvjconthtm)
^ 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 ox 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 fox 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 hereby certl at the above information is true and correct to the best of my knowledge.
Signature (/ Date
~ae~ 0.1/ ~ ,~ L~4C ~
Print Name
7