HomeMy WebLinkAboutAPPLICATION, BP - 06-00495 - 1721 Clements Ln - New SFR MechanicalZ
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City of Rexburgl MadisoWounty
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440 it iI
208- 359 -3020 X322
1721 Clements Ln -Cnty Mech
PARCEL NUMBER: � P W)l
SUBDIVISION: UNIT#
(Addressing is based on the information - must be accurate)
BLOCK# LOT#
OWNER: CONTACT PHO #
PROPERTY ADDRESS: I 7 Z I l � �
PHONE #: Home Work ( �3i - �C Cell _ f3
r OWNER MAILING ADDRESS: P 0 CITY: ncio STATE• rll ZIP: &- 1
EMAIL FAX
APPLICANT (If other than owner) f
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
CITY:
STATE; ZIP EMAIL FAX
PHONE M Home ( ) Work ( ) Cell ( )
CONTRACTOR `
MAILING ADDRESS:
PHONE: Home#
EMAIL
How many buildings are located on this property? 0
Did you recently pu this property No If yes give owner's name)
Is this a lot split`NO YES (Please bring copy of new legal description of property)
PROPOSED USE: i :JU
(i.e., Single Family Residence, Multi Family,
N
Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION Under penalty of perjury, l 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.
MOTE: The building official may revoke a permit on approval issued under the provisions of the 2000 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. Permit void if not started within 180 days. Permit void if work
stops for 180 days. n
ignat re of Owne pplicant DATE
Do you prefer to be contacted by fax, email or hone? Circle One
WARNING — BUMLDING PE ST 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 he does not constitute plan approval.
4
0600495 ph
Work#
CITY STATE ZIP
Cell#
FAX
2
1 1eltsv Co mplete Ole �:'.tl .= 3'�3�i��i�ii.3i�� ��' ffv ga (t,,:iml doioif aj)IA #iii 6i NA for oon
NAME O Q Q, [ 1 G
PROPERTY AbDRESS Permit#
SUBDIVISION
Requi MECHANICAL
Mechanical Contractor's Name: l�1K u��f7 d G Business Name: Ce c A—
Address 0,9 13j % zS �d City sc, � gz 7'),� State E - Zip ty�
Contact Phone: (,2vg) 3 fo - G'C� Business Phone:
Email Fax
Mechanical Estimate $ (Commercial/Multi Family Only)
F�S & APPLLgNCES COUNT
11 Furnace
Conditioner Combo
eat Pump
, furnace/Air
ir Conditioner
L Evaporative Cooler
Unit Heater
n Space Heater
n A Decorative gas - fired appliance
n_ Incinerator System
11 A Boiler
Pool Heater
(Single Family Dwelling Only)
Exhaust or Vent Ducts
( Dryer Vents
I Range Hood Vents
(� Cook Stove Vents
_ Bath Fan Vents
n 9 other similar vents & ducts:
1 Similar fixtures or Appliances
? Fuel Gas Pipe Outlets including stubbed in or future outlets
�'1 A Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) (� Oil Coal Fireplace Electric
Mechanical Sizing Calculations must be submitted with Plans & Application
Po' t of Delivery must be shown on plans.
^� 3-6 /s
i n,itury �P l.is,en ;_� C'ontraclair License numb r If ate
1 The City of Rexburg 's permit fee schedule is the same as required by the State of Idaho