HomeMy WebLinkAboutALL DOCS - 08-00024 - Perfect Tan - PlumbingCITY OF AEXBUG
BUILDING PERMIT APPLICATION Plea;
19 E MAIN, REXBURG, ID. 83440
208- 359 -3020 X326
•
0800024
Perfect Tan - Plumbing
PARCEL NUMBER C I Lk 4- ` & We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
is based on the intormatlon - must be
CONTACT PHONE #
PROPERTY ADDRESS: Ag � �1 Z-d i� 5
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: CITY: STATE: ZIP:
EMAIL FAX
�PPLICAIVT (If other than owner) LL ( --4-k; --4-t; /rl a � r'
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS �I iV ) � �'l7tcZ�.Gz C rG c c�ild
STATE ZIP 3 2C l EMAIL kr % rj{f CG�LYAl�
PHONE #: Home ( ) Work (2,vc4 232 -'2 -00cl Cell (cy) 2.6 - 2/ 3
How many buildings are located on this property?
Did you recently purchase this property ?� Yes (If yes give owner's name)
Is this a lot split? (�O, YES (Please bring copy of new legal description of property)
PROPOSED USE: 00 M" 2
(.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 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.
Signature' f Owner /Applicant DATE
Do you prefer to be contacted by fax, email or hone, Circle One
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 Jauuar�L 2(105.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval
**Building Permit Fees are due at time of application** **Building Permits are void if your check does not clear'*
N
Building Safety Department ;o F4tXg�R�, e I T Y O F
City of Rexburg ' nr�T mG
1� v 1t
19 E. Main ionetlh @rexburg.org Phone: 208.359.3020 ext 326 OW Family Community
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name T— Address
City
Being first duly sworn upon oath, depose and say:
i D ?3201
State
(If Applicant is also Owner of Record, skip to B)
That I am the ref qrd owner of the proj?erty described on the attached, and I grant my
permission to:
Name Address
to submit the accompanying application pertaining to that property.
B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any
claim or liability resulting from any dispute as to the statements contained herin or as to the
ownership of the property which is the subject of the application.
Dated this day of _l ,J/U"' 20
Signature
Subscribed and sworn to before me the day and year first above written.
NOTARY PUBLIC
LA RAE L. BALL Notary Pub&
STATE OF IDAHO
Residing at: , I,t'
My commission expires:
K3
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a
Please complete the entire Application!
NAME 5 j ` t
If the question does not apply fill in NA for non applicable
►
PROPERTY ADDRESS )fto i1cs Permit#
SUBDIVISION
Dwelling Units: Parcel Acres:
SETBACKS
FRONT SIDE SIDE BACK
Remodeling Your Building /Home ( need Estimate $
SURFACE SQUARE FOOTAGE. • (Shall include the exterior wall measurements of the building)
First Floor Area Unfinished Basement area
Second floor /loft area Finished basement area
Third floor /loft area Garage area
Shed or Barn Carport /Deck (30" above grade)Area
Water Meter Quantity: 1 Water Meter Size:
Requiredffl
PLUMBING
Plumbing Contractor's Name: / ��� �� "1 Ze ✓ Business Name: ��µ�` �® CYc/,
Address
Contact Phone: (Z-6 ff) 2 3.2 - Z Z `) 2 Business Phone:
Email C , 4u�j co 4 v -e i / . Coca -. Fax 00 f3 - - f37
FMZRE COU7VT & r W hed &tares)
Clothes Washing Machine Sprinklers
Dishwasher Tub /Showers
Floor Drain Toilet /Urinal
Garbage Disposal
Hot Tub /Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing
Water Heater
Water Softener
(Commercial Only)
Coo" ?71 / -0
License number Date
5Hrg's permit fee schedule is the same as required by the State of Idaho
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