HomeMy WebLinkAboutAPPLICATION - 07-00371 - 1384 N 4000 W - Gas LineCITY OF REXBURG •
07 003 71
MECHANICAL PERMIT APPLICATION Please cc 1384 N 4000 W -Casty Mech
19 E MAIN REXBURG ID. 83440 If the auestic
208 - 359 -3020 X326
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PARCEL NUMBER: -- rt"We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
CONTACT PHONE # _ q6 — 5 - z4 q7
PROPERTY ADDRESS: ,/�Oq &,
PHONE #: Home (Z( ?, ' Work Cell ( )
OWNER MAILING ADDRESS: �2dAl a_ CITY: STATE:ZaZIP: c p
EMAIL FAX
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as a east for o4mer must
APPLICANT INFORMATION: ADDRESS / IV91V LJ�6W VZ, CITY:
STATE; �L � ZIP6 EMAIL
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PHONE #: Home ( ob) ,35 -q-qF __ Work (20$ M -574 Cell kg) 31D —5'W ?
CONTRACTOR a5
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
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? YES (Please bring copy of new legal description of property)
PROPOSED USE: i .ua� /p(
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, G age, ommercial, Ad ition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: under penalt 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 hiterrnational Code in cases of any false statement or misrepresentation of fact in
the application or on the plans on which the pepinit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
Signature — oTOwner /Applicant
FAX
0/ /
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 Safety Department
City of Rexburg
19 E Main jonellh@rexburg.org
Rexburg, ID 83440 www.rexburg.org
Phone: 208.359.3020 x326
Fax: 208.359.3024
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NAME Kf (,% it
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!! MECHANICAL
Mechanical Contractor's Name yGrT- Business Name: ,�7l�yo
Address f �i G /1/ � °/� City State Zip e_j P�
Cell Phone: 3 _o/ 3 Business Phone:
Fax:( ) 31 YV — Email
Mechanical Estimate $ (Commercial/Multi Family Only)
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
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Pool Heater / �//� (^
Fuel Gas Pipe Outlets including stubbed in or future outlets
Heat (Circle all that apply) �s Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature o Licensed Contractor
The City of Rexburg's
License number
fee schedule is the same as
Date
the State of Idaho