HomeMy WebLinkAboutAPPLICATIONS - 08-00004 - 445 Linden - MechanicalCITY-OF REXBURG •
MECHANICAL PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208 - 359 -3020 X326
PARCEL NUMBER:
SUBDIVISION:
I •
Please co 0800004
If the questio 445 Linden -Boren
( We will provide this for you)
UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
OWNER: 4E � t , ✓G A# CONTACT PHONE # �
PROPERTY ADDRESS: !f ys �[; ,� g1 g r ,,. ye — u 6, zp S 3 '/ , r o
PHONE #: Home ��� 1.7�7F Work (0 Cell Zoe)
OWNER MAILING ADDRESS: �yf��� CITY: STATE _ ZIP:: $T 3 �
EMAIL FAX
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 (
CITY:
WALL
Cell (
CONTRACTOR
MAILING ADDRESS: ���. �� on S- CITY f, STATE _-jrj_ ZIP !F31f * a
PHONE: Home# _ 5g7,?yJ Work#
Cell# 3 5/ffbf�Qa
EMAI „...._, . 1 - ,,, - G FAZK
How many buildings are located on this property? /
Did you recently purchase this property ?40 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, M hi Family, Apara
Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty 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
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 the plans on which the permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
Signatu of Owner /Applicant DATE
ZIP EMAIL
Do you prefer to be contacted by fax, email o ho Circle One
WARNING — BUILDING P 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
Building Safety Department
City of Rexburg
19 E Main janellh@rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
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C I T Y OF
MXBURG
1111 America's Family Community
NAME d!E�IA
PROPERTY ADDRESS
SUBDIVISION
C_ _ Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: Qec�sles Nt.���.�. Business Name:
Address a3 Z Q - $moo S, City _A; eA State ZRW Zip
Cell Phone: G ya Business Phone: (,'p � fe ll
Fax: (
Email ��,- - �-,,_� S,y, c�,�•,
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
X _ Furnace I 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
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.
gnature of Licensed Contractor
The City of Rexburg's
mod
License number
schedule is the same as
by the State of Idaho
/- a 3-t S:
Date