HomeMy WebLinkAboutAPPLICATION - 07-00612 - 522 Island St - New SFR MechanicalCit Rexburg/ Madisonfounty PF
�' f 0700612
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440 522 Island- Taylor
208 - 359 -3020 X322
PARCEL NUMBER: Pbl - yLN b I bb l a ( We will provide this for you)
SUBDIVISION: UNIT #_ BLOCK # f
(Addressing is based on the information - must be accurate)
OWNER 1_= T - r�r'x r i rz +� f e Y� CONTACT PHONE #
PROPERTY ADDRESS:
PHONE #: Home ( ) Work ( ) Cell ( - q ' 60
' OWNER MAILING ADDRESS: /�c >� �- CITY: STATE:�ZIP:
'� EMAIL_ FAX
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner most accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR
MAILING ADDRESS:
PHONE: Home#
EMAIL
CITY STATE ZIP
Work# Cell#
FAX
How many buildings are located on this property? i
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: ; 1 I L j»
(i.e., Single Family Residence, Multi Fat ily, Apartments, R
VIX
CITY:
Garage, Commercial, 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 plans on which the permit or approval was based. Permit void if not started within I80 days. Permit void if work
stops for 180 days.
- ) J Ju��� L� / L 07
Signature of Owner /Applicant () DA h
loo you prefer to be contacted by fax, email o phon Circle One
WARNING — BURDING PE MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non- refundable and are paid In full at the time of application beginning Januarp 1, 2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval.
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NAME
PROPERTY ADDRESS 5 L 2- Zs'flyn -cL
SUBDIVISION L. akz n , , e n -.e
Permit#
Required!
MECHANICAL
Mechanical Contractor's Name: _yu C; , 1, -r\ " Business Name:
Address
City
Contact Phone: ( ) Business Phone:
Email Fax
Mechanical Estimate S (Commercial/Multi Family Only)
State Zip
FIXTURES A APPLL9NCES 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
Pool Heater
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 Electric
other similar vents & ducts:
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
1{ E3i1 171'' ;
4 0 1A)IN 1/l_ � ?_ - I c -- c 7
Date
(l NA1: fpJ:511 11 diJ ei Tjl _,% Jol 11ol;
Dryer Vents
Range Hood Vents
Cook Stove Vents
3 Bath Fan Vents
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
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