HomeMy WebLinkAboutAPPLICATION - 07-00626 - 148 Kelly Johnson Way - Gas LineCITY OF REXBURG •
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0700626
MECHANICAL PERMIT APPLICATION Pleas 149 Keller Johnson Wav- Airplane H anger
19 E MAIN, REXBURG, ID. 83440 If the qi Added (Jas L ine e
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)
CONTACT PHONE # - Dpl - Ito 1
PROPERTY ADDRESS:
PHONE #: Home (1v4) 3Su 7 599 Work (2oar) �_ c f - al e f Cell I - 2,10
OWNER MAILING ADDRESS: - 7" y1 5oot C CITY: a ad Cij. STATE:A!9 ZIP: 9)yy
EMAIL AX __ 1..
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 CITY:
STATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
now many mixtmgs 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 perjur 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
r and g Commissiob truthful and correct. I agree to comply with all City regulations and State laws relating to the
atter of this ap the City to enter upon the above - mentioned property for inspections purposes. NOTE: The
fficial may ons of the 2003 International Code in cases of any false statement or misrepresentation of fact in
ation or o e plan which tl5e permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
Signature f Owner /Applicant DATE
Do yo 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