HomeMy WebLinkAboutAPPLICATION - 07-00021 - 81 S 3818 W - New SFR MechanicalCI TY OF REXB URG 0 0
BUILDING PERMIT APPLICATION Please 0700021
19 E MAIN, REXBURG, ID. 83440 If the que
208- 359 -3020 X322 81 S 3 818 W - Cnty Mech
PARCEL NUMBER:
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
PROPERTY ADDRESS:
PHONE #: Home ( )
OWNER MAILING ADDRESS:
EMAIL
Work ( )
IV%"
I
Cell ( )
CITY: STATE: ZIP:
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:
CITY:
ZIP EMAIL
PHONE #: Home ( )
Work ( )
FAX
Cell ( )
CONTRACTOR U\ &; At j
MAILING ADDRESS: ?(l, 9 `] CITY: Iau 01 STATE � 44V
PHONE: Home# Work# 3 � CA i I 1 Cell# 3 9 0 1 713 3
EMAIL _ FAX _3 cJ
nuw uiaiiy ounuings are iocatea on tins 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 perjur 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 — 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 you check does not clear"
_CONTACT PHONE #
. _ 0
Please complete the ent ire Application! If the question does not apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS Permit#
SUBDIVISION
Required!!! MECHANICAL
•
Mechanical Contractor's Name: V, e l -4a Business Name:
Address City State Zip
Contact Phone: ( 390 -13 S `s Business Phone: (2-C C) 4111
Email Fax ZQg SS(, 5OSS
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL9NCES COUNT (Single Family Dwelling Only)
Furnace t Exhaust or Vent Ducts
_ Furnace /Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
I Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
Similar fixtures or Appliances
_I Dryer Vents
Range Hood Vents
Cook Stove Vents
2- 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
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
C7,
Signature of Licensed Contractor
The City of Rexburg's
License number Date
ree schedule is the same as required by the State of Idaho