HomeMy WebLinkAboutAPPLICATION - 07-00023 - 4781 N 495 W - New SFR Mechanical0 •
CITY OF REXBURG PEI
MECHANICAL PERMIT APPLICATION Please cow 7 0002
19 E MAIN, REXBURG, ID. 83440 If the question c 4781 N 495 W -Cnty Mech
208 - 359 -3020 X326
PARCEL NUMBER: Pi�r —�C W2 aJ 1 0 (We will provlcte this for you)
SUBDIVISION: Lc K � Lv re ,, e UNIT# BLOCK# 2 - LOT# I 't 2
(Addressing is based on the information - must be accurate)
m a CONTACT PHONE # Z 3 � I l 3 9
PROPERTY ADDRESS: q ? mo d( qq G W
PHONE #: Home ( ) Work ( ) Cell
OWNER MAILING ADDRESS: I f ? IV Ygsw CITY: 6 STATE: 8'3W
EMAIL 5 w e ( tvn 4 _� , lam' CoM,CZ ) lt ✓i
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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 CITY:
STATE; ZIP EMAIL FAX
PHONE #: Home (
Work ( ) Cell (
CONTRACTOR
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
How many buildings are located on this property? l
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Did you recently purchase this property? No �(If yes give owner's name) D��I e G , ti 7
Is this a lot split? (N�1) YES (Please bring copy of new le al description of property)
PROPOSED USE: Gt 04-1 CY !� ;PSG u2c
(i.e., Single Family Residence, Multi Family,
Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: under penalt 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 2003 International Code in cases of any false statement or misrepresentation of fact in
the app or on the plans on w ch the pe 't or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
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Signature of Owner /Applicant .�
Do you prefer to be contacted by fax, email or ho ? Circle One
WARNING — BUILDING PE MUST BE POSTED ON CONSTRUCT 14
Plan fees are non - refundable and are paid in full at the time of application beginning
City of Rexburg's Acceptance of the plan review fee does not constitute plan o
DATE
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CITY OF REXBURG
Building Safety Department
City of Rexburg
19 E Main ionellh@rexburg.org Phone: 208.359.3020 x326
Rexburg, 1D 83440 www.rexburg.org Fax: 208.359.3024
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C I T Y OF
REXBURG
America's Family Community
NAME , - 0 41
PROPERTY ADDRESS `� 7 S A0 5'
SUBDIVISION Lc)
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: Otd rt P (- Business Name:
Address City State Zip
Cell Phone: (266 _7 ( :- (v L(3 R' Business Phone: ( )
Fax: ( )
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace _� Exhaust or Vent Ducts
Furnace /Air Conditioner Combo _�_ Dryer Vents
Heat Pump �_ Range Hood Vents
_ Air Conditioner Cook Stove Vents
Evaporative Cooler
Unit Heater
Bath Fan Vents
other similar vents & ducts:
Space Heater
Decorative gas -fired appliance
Incinerator System � � _
Boiler G�0.S Wcol es 4 e G � �b ( w 4 a
Pool Heater
5 Fuel Gas Pipe Outlets including stubbed in or future outlets
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
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Signature of Licensed Contractor License number I D to
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
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