HomeMy WebLinkAboutAPPLICATION - 07-00445 - 2891 W 5200 S - Mechanical}
City of Rexburgl Madison County 07t 0445
BUILDING PERMIT APPLICATION i' 1
19 E MAIN, REXBURG, ID. 83440 1 ' {, 2891 w 5200 S -Cnty Mech
208 - 359 -3020 X322
PARCEL NUMBER : �6� ;9 (We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
_7 ' � �72Q Z . CONTACT PHONE # f_)_U'0--- t
,poi -�3v
PROPERTY ADDRESS: qiA � \N. r'J 2W _ .
3 / - 5z
PHONE #: Home Work ( ) -let Cell W)
OWNER MAILING ADDRESS: 1(1! X25 > CITY: QF, STATE:ZIP:
EMAIL FAX
APPLICANT (If other than owner)
(Applicant if other than owner, a statement
to act as agent fof owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS 2R;VU ,L) Iwo N CITY: CF) n
STATE; L ZIP 93 y V 6 EMAIL FAX
PHONE #: Home ( ) Work ( } Cell (;61) 61 63 5
CONTRACTOR _ tJtXlie 1J7 Z4 pit, _ 1 'l �' i � rp (J ,664 �
MAILING ADDRESS: 2 ( I VJ. STATE ZIP
PHONE: Home# -e' Work# Cell# 20@ . 2 01 - (o�3cl C
EMAIL --b FAX _-A�)-
How marry buildings are located on this property? J _
Did you recently purchase this property s No es (If yes give ovvner's name)
Is this a lot split? 1 0 YES (Please bring copy of new legal description of property)
PROPOSED USE-
(i.e., Single Family Residence, Multi Family, Apartment , em e , ar= �ommercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION Under penalty 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 2000 International Code in cases of any false statement or
misrepresentation of fact in the application or on the ans on which the permit or approval was based. Permit void if not started within 180 days. Permit void if work
stops for 180 days.
a i 1 i o
Signature of Owner /Applicant DATE
Do you prefer to be contacted y fax, email phol Circl ne
WARNING — BUILDING PE MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non - refundable and are paid in full at the time of application beginning Janumv 1, 2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval.
2
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3 )f!l t� r�1
NAME
PROPERTY ADDRESS •2gt1 kk pbZt�o Permit#
SUBDIVISION
MECHANICAL
Mechanical Contractor's Name: L �,)��,�, Business Name: 1.1A
Address lq3M 1 W . F W ` City 2EA State J zip 03C
Contact Phone: Business Phone:
Email Fax -0-
Mechanical Estimate S (CommerciaUMniti Family Only)
FDffURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
1 �
Furnace /Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
_ Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Similar fixtures or Appliances
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) Gas Oil Coal Fireplace &ec c
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho