HomeMy WebLinkAboutAPPLICATION - 07-00421 - Leishman Electric - MechanicalCITY OF REXBURG 0700421
MECHANICAL PERMIT APPLICATION Please Leishman Electric- Mechanical
19 E MAIN, REXBURG, ID. 83440 If the qua
208 - 359 -3020 X326
PARCEL NUMBER �X? (We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
OWNER: L-r— r 541,w tit,`► F I (_Jv f (- CONTACT PHONE#
PROPERTY ADDRESS: I t'� AlyA� � Z,,I�}iJ � !'t
PHONE #: Home ( ) ZS( ; J Work ( ) Cell ( )
OWNER MAILING ADDRESS:
EMAIL
11 4
CITY:
STATE: ZIP:
APPLICANT (If other than owner
(Applicant if other than owner, a statement authorizing
APPLICANT INFORMATION: ADDRESS
fW:\
ZIP EMAIL
PHONE #: Home ( ) Work ( )
as agent for owner mus ac t
CITY:
FAX
Cell ( )_
CONTRACTOR
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? 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 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 International Code in cases of any false statement or misrepresentation of fact in
the application or on plans on permit or approval was based. Permit voidif not started within 180 days. Permit void if work stops for 180 days.
Signature of Owner /Applicant DA'PE
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
this application.)
Building Safety Department jk City of Rexburg
19 E Main janellh @rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
CITY OF
IBEX BURG
America's Family Community
NAME
PROPERTY ADDRESS Permit#
SUBDIVISION
Required!!! MECHANICAL
Mechanical Contractor's Name: V LA._)QN � , , l �,� ��� 4 Business Name:
( C
Address � � ��, � � 5 � City U x State – ,T- - rZ _Zip
Cell Phone: ( ) Business Phone: ( ) �?J�
Fax: ( )
Email
co
Mechanical Estimate $ �UD (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
_F urnace/Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
) — Fuel Gas Pipe Outlets including Stubbed in or future outlets
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
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
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho