HomeMy WebLinkAboutAPPLICATION - 07-00378 - 4648 Cedar Butte Rd - Gas Line0
CITE OF REXBURG
MECHANICAL PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208 - 359 -3020 X326
Pleas 0700378
If the c 4648 Cedar Butte -Cnty Mech
PARCEL NUMBER: ( We will provide this for you)
SUBDIVISION: UNIT# - 0 BLOCK# / LOT # _L7
(Addressing is based on the information - must be accurate)
I1
de
OWNER: ANCIVa tI /qm CONTACT PHONE
PROPERTY ADDRESS: 1 -!649 C6 � C / &LE
PHONE #: Home ( ) �S�p ��'�o� Work( ) Cell(
OWNER MAILING ADDRESS: rS'We CITY: STATE: ZIP:
EMAIL ,W y�,irzqe. FAX
r-0
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:
PHONE #: Home (
Work (
Cell (
FAX
CONTRACTOR
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
How many buildings are located on this Dronerty? /
Did you recently purchase this property? No % 'e (If yes give owner's name) M&AV. `A 1 ct /,�,te
Is this a lot split ?& 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 penalt of perjur I hereb certif 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 ma revf�
ke a permit on approv� issued under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the appl�i�n n of fact in or a tplan sr whicly the peYh i was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
0J /3 D�
DATE
CITY:
ZIP EMAIL
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
L.l
Building Safety Department
City of Rexburg
19 E Main ionellh @rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
NAME Jyt Ot A&t 1�
PROPERTY ADDRESS
SUBDIVISION
CITY OF
REXBURG
Americas Family Community
04 AexsU,p�
�� ld
Uv� O
z
L UAMS
re 46419 Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: QWAt�� Business Name:
Address City State
Cell Phone: ( ) Business Phone: ( )
Fax: ( ) Email
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES 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 Bath Fan Vents
Unit Heater other similar vents & ducts:
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
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.
Signature of Licensed Contractor License number Date
Zip
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho