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CITY OF AEXB URG 0 0
BUILDING PERMIT APPLICATION Pl 0600552 tion!
19 E hLAIN, REXBURG, ID. 83440 if cable 7 N 3rd E - Madera licable
208 - 359 -3020 X326
PARCEL NUMBER: 'Y 1� ,�1,1� I L' � k .. „ -- r l --. ---
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
CONTACT PHONE #
PROPERTY ADDRESS: 37 tJ , 3 r rx
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: Z40 (,2 16 1p'f Ave- CITY: oca « o _STATE: rd ZIP: S T ZO
EMAIL F
APPLICANT (If other than owner) N`ndL51+eC :?(U.Mit b&"'
(Applicant if other than owner, a statement authorizing applicant to act as agent f r owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS 1 43 , q CITY:
STATE; ZIP EMAIL tNl 0.S -fe r plat wtg FAX 5_3 g - 7 3 q z
PHONE #: Home ( ) Work ( ) g SD t'o Cell ( )
CONTRACTOR
MAILING ADDRESS: CITY STATE ZIP
PHONE #: Home ( ) Work ( ) Cell ( )
EMAIL F
IDAHO REGISTRATION # & EXP. DATE
How many buildings are located on this property?
Did you recently purchase this property? No Yes (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.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. Permit void i n ot started within 180 days. Permit void if work stops for 180 days.
0 ( ( I f 3
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
* *Building Permit Fees are due at time of application ** * *Building Permits are void if your check does not clear **
2
Please complete the Are A M 41
p Ap plication !
If the question does not apply fill in NA for non applicable
NAME
PROPERTY ADD SS Permit#
SUBDIVISION
Dwelling Units: Parcel Acres:
SETBACKS
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 Unfinished Basement are,
Second floor /loft area Finished basement area_
Third floor /loft area Garage area
She or Barn Carport /Deck (30" above
Water Meter Quantity:
*`r * * * * * * * * ** —Water Meter Size:
Required ef!
..P-.J-r, UMBING
Plumbing Contractor's Name: �KtOl & tP- t f Business Name: Q 5 - f 2C 1 l li
Address �''( G [ C City 77 State Zip s3 'lot
Contact Phone: Business Phone: ( )
Fax — 7 3 `t Z
FIXTURE COUNT (inclu&ngroughed fixtures
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub /Spa
Sinks (Lavatories, kitchens, bar, mop)
Plumbing Estimate $ (Commercial Only)
e2 uwu
Signature of Licensed Contractor
... _ . .......
The City of Bexbu
Sprinklers
Tub /Showers
Toilet /Urinal
Water Heater
Water Softener
C f (g3 r2 -31 oG rI -6- ",r) 6
License Number& Expiration Date Date
t fee schedule is the same as required by the State of Idaho
I