HomeMy WebLinkAboutAPPLICATION - 06-00573 - 1761 Clements Ln - New SFR MechanicalCity of Rexburgl Madisow'ounty
BUILDING PERMIT APPLICATION Please 0600573
19 MAIN, REXBURG, ID. 83440 I dw q 1761 Clements Ln -Cnty Mech lea
208- 359 -3020 X322
PARCEL NUMBER Y (!v`� I C' ( we will pruviuc uus tui yuu)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
PROPERTY ADDRESS:
CONTACT PHONE #
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: CITY:
EMAIL FAX
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR
MAILING ADDRESS: CITY
PHONE: Home#
EMAIL
Work# Cell #
FAX � S�
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 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.
Signature of Owner /Applicant DATE
Do you prefer to be contacted by fax, email or phone? Circle One
WARNING — BUIIAING 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 he does not constitute plan approval.
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STATE: ZIP:
CITY:
STATE ZIP
I I I Ca'se,ct3nI pletc the clite, A pplication! it' tile sisae tioit ±ftW)I .sisiti.y' tiII Iit 1 NA this' IIoII
NAME
PROPERTY ADDRESS Permit#
SUBDIVISION
Required! MECHANICAL
Mechanical Contractor's Name: fi Business Name: _
Address po 45" City k �, State
Contact Phone: (
Email
Business Phone: (
Fax
Mechanical Estimate $ (Commercial/Multi Family Only)
Zip
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
Similar fixtures or Appliances
( Dryer Vents
Range Hood Vents
Cook Stove Vents
Z Bath Fan Vents
other similar vents & ducts:
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
w
2006
REXBURG
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
iglc
:ai�,nat�ar� oI'Lir,f,nsed Contractor License number
R ziitircut ._
1 3 n/oy o(�o
Date
I The City of Rexburg s permit fee schedule is the same as required by the State of Idaho
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